Barriers and facilitators of evidence-based management of patients with bacterial infections among general dental practitioners: a theory-informed interview study

Dental antibiotic use in British Columbia from 1996 through 2023: Are we backsliding?

BACKGROUND

Dentists in the United States and Canada have higher rates of prescribing broad-spectrum spectrum antibiotics than dentists in some other Western countries. The authors provide an overview of dental antibiotic prescribing trends from British Columbia, Canada.

METHODS

The data include all prescriptions filed from pharmacies in British Columbia from 1996 through 2023. Dental antibiotic prescribing trends were explored visually and stratified according to patient-related characteristics, type of health service area, type of antibiotic, duration of therapy, and dentist's experience. Interrupted time series regression analysis was conducted to investigate the impact of the COVID-19 pandemic on dental antibiotic prescribing.

RESULTS

Dentistry accounted for an increasing proportion of overall antibiotic consumption in British Columbia. Dental prescriptions increased to a peak rate during the COVID-19 pandemic and remained elevated into 2023. The median duration of prescription converged toward a 7-day supply during the study period.

CONCLUSIONS

The authors documented how a decreasing trend in dental antibiotic prescribing prepandemic has been interrupted by means of continuously high rates after that event.

PRACTICAL IMPLICATIONS

Renewed efforts to ensure appropriateness of dental antibiotic prescribing are needed.

Evaluation of Antibiotic Use for Dental-Related Infections in Dental Clinics Associated With an Academic Safety Net Institution

This retrospective study found lower antibiotic prescribing rates by outpatient dentists than previous literature, but with deviations from guideline recommendations in antibiotic indications and durations of treatment for oral pain and swelling. These findings will guide future stewardship interventions to promote guideline-directed therapy plans.

Barriers and facilitators to guideline concordant dental antibiotic prescribing in the United States: A qualitative study of the National Dental PBRN

OBJECTIVES

While factors contributing to dental antibiotic overprescribing have previously been described, previous work has lacked any theoretical behavior change framework that could guide future intervention development. The purpose of this study was to use an evidence-based conceptual model to identify barriers and facilitators of appropriate antibiotic prescribing by dentists as a guide for future interventions aimed at modifying antibiotic prescribing.

METHODS

Semi-structured interviews were conducted with dentists from the National Dental Practice Based Research Network (PBRN) exploring patient and practice factors perceived to impact antibiotic prescribing. Audio-recorded telephone interviews were transcribed and independently coded by three researchers. Themes were organized around the COM-B model to inform prospective interventions.

RESULTS

73 of 104 dentists (70.1%) were interviewed. Most were general dentists (86.3%), male (65.7%), and white (69.9%). Coding identified three broad targets to support appropriate dental antibiotic prescribing among dentists: (1) increasing visibility and accessibility of guidelines, (2) providing additional guidance on antibiotic prescribing in dental scenarios without clear guidelines, and (3) education and communication skills-building focused on discussing appropriate antibiotic use with patients and physicians.

CONCLUSIONS

The findings from our study are consistent with other studies focusing on antibiotic prescribing behavior in dentists. Understanding facilitators and barriers to dental antibiotic prescribing is necessary to inform targeted interventions to improve appropriate antibiotic prescribing. Future interventions should focus on implementing multimodal strategies to provide the necessary support for dentists to judiciously prescribe antibiotics.

'Well, in dentistry the dentist is always the boss': a multi-method exploration of which organisational characteristics of dental practices most influence the implementation of evidence-based guidance

OBJECTIVE

To investigate which organisational characteristics of primary care dental practices influence the implementation of evidence-based guidance.

DESIGN

A multimethod study set within primary care dentistry in Scotland comprising: (1) Semistructured interviews with dental teams to inform development of a self-report questionnaire exploring the translation of guidance in primary care dentistry and (2) A questionnaire-based survey and case studies exploring which organisational characteristics influence knowledge translation.

RESULTS

Interview data identified three themes: leadership, communication and context. Survey data revealed compliance with recommendations from three topics of dental guidance to be variable, with only 41% (emergency dental care), 19% (oral health assessment and review) and 4% (drug prescribing) of respondents reporting full compliance. Analysis revealed no significant relationship between practice characteristics and compliance with emergency dental care or drug prescribing recommendations. Positive associations were observed between compliance with oral health assessment and review recommendations and having a practice manager, as well as with the type of treatment offered, with fully private practices more likely, and fully National Health Service practices less likely to comply, when compared with those offering a mixture of treatment. Synthesis of the data identified leadership and context as key drivers of guidance uptake.

CONCLUSIONS

Evidence-based dental recommendations are not routinely translated into practice, with variable leadership and differing practice contexts being central to poor uptake. Guidelines should aim to tailor recommendations and implementation strategies to reflect the complexities and varying contexts that exist in primary care dentistry, thus facilitating the implementation of evidence-based guidance.

Influences on nurses' engagement in antimicrobial stewardship behaviours: A multi-country survey using the Theoretical Domains Framework

BACKGROUND

Antimicrobial resistance (AMR) is significantly affected by inappropriate antibiotic use, and is one of the greatest threats to human health. Antimicrobial stewardship (AMS) is a programme of actions promoting responsible antimicrobial use, and is essential for limiting AMR. Nurses have an important role to play in this context.

AIM

This study investigated the determinants of nurse AMS behaviours and the impact of past training.

METHOD

A cross-sectional multi-country survey design with mixed methods was employed. Participants were 262 nurses (223 female; mean age = 44.45; SD = 10.77 years) from ten nationalities, with individual survey links sent via professional networks in 5 countries, alongside Twitter. Nine AMS behaviours and 14 behavioural determinants were quantitatively assessed using the Theoretical Domains Framework (TDF), and mapped to the COM-B (Capability, Opportunity, Motivation - Behaviour) model. Analysis identified differences between nurses with and without AMS training. The influence of COVID-19 on AMS behaviour was qualitatively investigated using free text data.

FINDINGS

Nurses performed all nine AMS behaviours, which were significantly higher (t(238) = -4.14, p < .001), by those who had training (M = 53.15; SD = 7.40) compared to those who had not (M = 48.30; SD = 10.75). Those with AMS training scored significantly higher in all of the TDF domains. The TDF was able to explain 27% of the variance in behaviour, with 'Skills' and 'Behavioural Regulation' (e.g. ability to self-monitor and plan), shown to be the most predictive of AMS actions. Both of these domains are situated in the Capability construct of COM-B, which can be enhanced with the intervention strategies of education and training. An increase in AMS behaviours was reported since COVID-19, regardless of previous training. Six core themes were linked to AMS: 1) Infection prevention and control, 2) Antimicrobials and antimicrobial resistance, 3) The diagnosis of infection and the use of antibiotics, 4) Antimicrobial prescribing practice, 5) Person-centred care, and 6) Interprofessional collaborative practice.

CONCLUSION

This research, has identified the significant benefit of nurse training on AMS behaviour, and its determinants. Those who had training, scored higher in all TDF determinants of behaviour, compared to those who had had no training, resulting in higher Capability, Opportunity and Motivation to perform AMS behaviours. AMS education and training should be offered to nurses to enhance these factors. Future research should consider the optimal level of training to optimise AMS behaviour, with a focus on developing skills and behavioural regulation.

A qualitative approach to examining antimicrobial prescribing in the outpatient dental setting

OBJECTIVE

To understand barriers and facilitators to evidence-based prescribing of antibiotics in the outpatient dental setting.

DESIGN

Semistructured interviews.

SETTING

Outpatient dental setting.

PARTICIPANTS

Dentists from 40 Veterans' Health Administration (VA) facilities across the United States.

METHODS

Dentists were identified based on their prescribing patterns and were recruited to participate in a semistructured interview on perceptions toward prescribing. All interviews were recorded, transcribed, and double-coded for analysis, with high reliability between coders. We identified general trends using the theoretical domains framework and mapped overarching themes onto the behavior change wheel to identify prospective interventions that improve evidence-based prescribing.

RESULTS

In total, 90 dentists participated in our study. The following barriers and facilitators to evidence-based prescribing emerged as impacts on a dentist's decision making on prescribing an antibiotic: access to resources, social influence of peers and other care providers, clinical judgment, beliefs about consequences, local features of the clinic setting, and beliefs about capabilities.

CONCLUSIONS

Findings from this work reveal the need to increase awareness of up-to-date antibiotic prescribing behaviors in dentistry and may inform the best antimicrobial stewardship interventions to support dentists' ongoing professional development and improve evidence-based prescribing.

A dentist's dilemma: sharing wellbeing concerns to safeguard Scotland's children

Introduction Over a decade ago, Getting it right for every child (GIRFEC) introduced the 'Named Person' as a central contact with whom professionals could share 'wellbeing' concerns in Scotland, aiming to promote inter-agency working to avoid potential child protection issues. The mandatory 'Named Person' scheme has since been repealed but the professional's responsibility to share concerns at wellbeing level remains.Aims To explore general dental practitioners' (GDPs') understanding of a child's 'wellbeing', along with the investigation of influencing factors on behaviour when sharing concerns at wellbeing level.Methods Qualitative one-to-one semi-structured telephone interviews with GDPs. Themes arising from transcriptions were organised into the Theoretical Domains Framework.Results In total, 11 dentists (five men and six women) participated. Risks to wellbeing included only attending in pain and dental neglect. There was good awareness of the 'Named Person' and triggers to sharing suspicions were identified, which were concern severity, multiple concerns and own intuition. Multiple barriers (eg poor knowledge, fear of consequences, environment) and enablers (eg professional responsibility and influences, positive consequences) influenced decisions to refer. GDPs struggled to differentiate between wellbeing and child protection.Conclusion Barriers and facilitators to sharing wellbeing suspicions are similar to child protection. GDPs may benefit from further training when safeguarding at a wellbeing level.

'You had to do something': prescribing antibiotics in Scotland during the COVID-19 pandemic restrictions and remobilisation

Introduction The COVID-19 pandemic brought about seismic change for dentistry including the direction to provide remote advice and prescribe analgesia and antimicrobials. The possibilities for care have widened, but the impact of both restrictions and remobilisation on antibiotic prescribing is not known.Aims To report the impact of COVID-19 restrictions and remobilisation on dental antibiotic prescriptions and explore dentists' intentions and attitudes towards antibiotic prescribing.Design and setting Public Health Scotland national prescribing and claims data are reported alongside an online survey of Scottish general and public health service dentists including closed and open-ended questions.Results Antibiotic prescribing rose by 49% following the suspension of routine dental care, to a peak of 34,993 antibiotics (July 2020). The data also show that since the remobilisation of NHS dental care, antibiotic prescribing remains raised at levels around 28% higher than pre-pandemic. The survey highlights dentists' frustrations and concerns about this increased use of antibiotics. Most dentists intend to reduce their prescribing; however, significant challenges to this being realised were raised.Conclusions The previous success within dentistry to protect against the development of antimicrobial resistance has suffered a knock-back during the pandemic. A renewed focus on reducing unnecessary antibiotics within dentistry is required but, crucially, needs to be approached sensitively alongside the current backdrop of challenges within the service.

Factors, Perceptions and Beliefs Associated with Inappropriate Antibiotic Prescribing in German Primary Dental Care: A Qualitative Study

Dentists account for up to 10% of all prescribed antibiotics in primary care, with up to 80% being inappropriate. Targeted approaches to change prescription behavior are scarce. This study aimed at identifying specific barriers and facilitators for prudent antibiotic use in German dentistry by using qualitative methods. Nine in-depth interviews and two focus group discussions with another nine dentists were conducted and analyzed thematically. Dentists described being conflicted by the discordance of available treatment time and the necessity of thorough therapy. Lacking the opportunity of follow-up led to uncertainty. Dentists felt a lack of medical competency concerning prophylaxis for infectious endocarditis. A lack of empowerment to make therapeutic decisions interfered with guideline-conformity. The communication with fellow physicians is conflictual and improvement was wished for. In consequence, dentists felt pressure by potential medico-legal liability. Patients demanding quick and easy pain relief put extra strain on the interviewed dentists. Our hypotheses concord with preliminary data, mainly from the UK, but highlighted specifically medico-legal concerns and interprofessional communication as even greater barriers as described before. Tailored interventional concepts based on our findings may have the potential to lower antibiotic prescriptions in German primary dental care.

Selective Caries Removal in Permanent Teeth (SCRiPT) for the treatment of deep carious lesions: a randomised controlled clinical trial in primary care

BACKGROUND

Dental caries is one of the most prevalent non-communicable disease globally and can have serious health sequelae impacting negatively on quality of life. In the UK most adults experience dental caries during their lifetime and the 2009 Adult Dental Health Survey reported that 85% of adults have at least one dental restoration. Conservative removal of tooth tissue for both primary and secondary caries reduces the risk of failure due to tooth-restoration, complex fracture as well as remaining tooth surfaces being less vulnerable to further caries. However, despite its prevalence there is no consensus on how much caries to remove prior to placing a restoration to achieve optimal outcomes. Evidence for selective compared to complete or near-complete caries removal suggests there may be benefits for selective removal in sustaining tooth vitality, therefore avoiding abscess formation and pain, so eliminating the need for more complex and costly treatment or eventual tooth loss. However, the evidence is of low scientific quality and mainly gleaned from studies in primary teeth.

METHOD

This is a pragmatic, multi-centre, two-arm patient randomised controlled clinical trial including an internal pilot set in primary dental care in Scotland and England. Dental health professionals will recruit 623 participants over 12-years of age with deep carious lesions in their permanent posterior teeth. Participants will have a single tooth randomised to either the selective caries removal or complete caries removal treatment arm. Baseline measures and outcome data (during the 3-year follow-up period) will be assessed through clinical examination, patient questionnaires and NHS databases. A mixed-method process evaluation will complement the clinical and economic outcome evaluation and examine implementation, mechanisms of impact and context. The primary outcome at three years is sustained tooth vitality. The primary economic outcome is net benefit modelled over a lifetime horizon. Clinical secondary outcomes include pulp exposure, progession of caries, restoration failure; as well as patient-centred and economic outcomes.

DISCUSSION

SCRiPT will provide evidence for the most clinically effective and cost-beneficial approach to managing deep carious lesions in permanent posterior teeth in primary care. This will support general dental practitioners, patients and policy makers in decision making. Trial Registration Trial registry: ISRCTN.

TRIAL REGISTRATION NUMBER

ISRCTN76503940. Date of Registration: 30.10.2019. URL of trial registry record: https://www.isrctn.com/ISRCTN76503940?q=ISRCTN76503940%20&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search .

An investigation into possible factors that may impact on the potential for inappropriate prescriptions of antibiotics: a survey of general dental practitioners' approach to treating adults with acute dental pain

Objective To investigate factors that might influence inappropriate prescriptions of antibiotics (ABs) by UK-based general dental practitioners (GDPs) in their management of acute dental pain in adults in primary dental care.Methods A questionnaire was circulated via social media to UK-based GDPs. The questionnaire examined GDPs' likelihood of issuing an inappropriate AB in two hypothetical clinical scenarios.Results A total of 205 questionnaires were completed, of which 198 were included for analysis. The resulting data were analysed to try and identify factors that correlated with an increased likelihood of an inappropriate AB prescription being issued for each clinical scenario. The results suggested the following factors as being associated with a statistically greater chance of the survey respondent issuing an inappropriate AB prescription: no postgraduate qualification; received their primary dental qualification from a non-UK university; scheduled appointments of less than 20 minutes; and low confidence in their ability to provide adequate local anaesthesia for the patients in the clinical scenario.Conclusions Four factors were shown to be associated with dentists' stated intention to prescribe ABs for acute dental pain, not in accordance with guidance. These results should guide further research to understand the significance of appropriate AB prescribing on the quality of urgent dental care. While the total number of respondents was too low to enable the results to be generalised, it is hoped that the results may help guide future research. Further studies could focus on these factors to understand more about their impact on the urgent care of adult patients in pain. The impact of the restrictions caused by the response to COVID-19 needs to be considered.

Using a behavioural framework to optimize antibiotic prescribing by family medicine residents

This article was migrated. The article was marked as recommended. Background and objectives:Overprescribing of antibiotics in primary care is a prominent concern in the context of increasing antimicrobial resistance worldwide. Medical trainees are a key group to deliver thoughtful antimicrobial stewardship training. This study examined the factors influencing antibiotic prescribing for upper respiratory tract infections (URTI) by family medicine residents in order to identify educational interventions. Methods: Using purposive sampling of family medicine residents, semi-structured interviews were conducted until thematic saturation was reached. Interviews were coded into the domains of the Theoretical Domains Framework (TDF). Belief statements were created to characterize each domain and categorized as enablers or barriers to appropriate prescribing. Domains were plotted on the Behaviour Change Wheel (BCW) and intervention functions identified. Results:Twelve participants were interviewed. Nine domains of the TDF were relevant to antibiotic prescribing. Social influence was a prominent theme with the preceptor and patient being key influences on resident prescribing. Learning goals were also a key theme including the desire to strengthen independent clinical decision-making skills and improve antibiotic knowledge. Residents' beliefs about capabilities were challenged when faced with diagnostic uncertainty. Additional domains included: professional role; environmental context and resources; intentions; beliefs about consequences and capabilities, and knowledge. Using the BCW, nine intervention functions were identified to change antibiotic prescribing behaviour. Conclusion: This study found nine domains of the TDF were relevant to family medicine resident antibiotic prescribing for URTI. Nine intervention functions could be used to guide intervention design.

Antibiotics and toothache: a social media review

OBJECTIVES

Antibiotics are inappropriate for the treatment of toothache, yet many seek them. Social media allows users to express their opinions, share experiences and offer support. This study used social media to investigate the public's experiences of, and attitudes towards, antibiotics for toothache.

METHODS

A systematic search of posts on Facebook and Twitter was undertaken. Eligibility criteria were applied to select relevant social media posts for thematic analysis of word content. An inductive descriptive coding system was developed from the data and exemplary quotes were identified to illustrate the themes and subthemes identified. Key findings Searches identified 174 posts, of which 144 were selected for analysis. Five themes were identified: experience and expectations, self-care and professional treatment, access to dental care, quality of life and coping strategies. The belief that antibiotics are an appropriate treatment for a toothache was widespread. Antibiotic-seeking behaviour was related to access to professional dental care, including avoiding dental appointments due to dental anxiety and the perceived affordability of dentistry. A range of strategies to cope with the severe impact toothache was having on people's quality of life were identified, from prayer to antibiotics.

CONCLUSIONS

Social media is used extensively to seek antibiotics, avoid dental treatment and provide support to people with toothache. A general belief that antibiotics are an appropriate and necessary treatment for toothache exists. This improved understanding about the factors driving antibiotic-seeking behaviour provides new targets for the development of approaches to tackling antibiotic resistance, by reducing unnecessary antibiotic use in dental clinics and beyond.

Audit and feedback with or without training in-practice targeting antibiotic prescribing (TiPTAP): a study protocol of a cluster randomised trial in dental primary care

BACKGROUND

Antimicrobial resistance is an increasingly serious threat to global public health and patient safety. Overuse of antibiotics has aggravated this issue. Around 7% of all antibiotics in Scotland are prescribed by dentists. Audit and feedback has been shown to decrease these prescriptions, but there is evidence that dentists still prescribe unnecessarily. Our aim is to compare the effectiveness of a theory-informed in-practice training session (TiPTAP) in addition to individualised audit and feedback, with audit and feedback alone for reducing antibiotic prescribing by NHS dentists working in NHS primary care dental practices.

METHODS

We will conduct a 2-arm parallel cluster randomised trial: out of 228 practices, 114 will be randomised to the theory-informed in-practice training session targeting antibiotic prescribing and individualised audit and feedback; 114 practices will be randomised to audit and feedback alone. The theory-informed session will include (a) an introductory session including several behaviour change techniques; (b) problem solving discussion, setting and recording action plans; (c) practice-level prescribing feedback discussion. The primary outcome is the number of antibiotic items per 100 NHS treatment claims over a 1-year period post-randomisation for each dentist. Secondary outcomes are the number of amoxicillin 3 g and broad spectrum antibiotics prescribed per 100 NHS treatment claims over a 1-year period; amoxicillin 3 g and broad spectrum antibiotics defined daily doses of antibiotics per 100 claims. Process measures include fidelity, knowledge, and confidence. Primary and secondary outcomes will be obtained using routine data.

DISCUSSION

This study provides the opportunity to robustly assess the effect of adding an in-practice training co-intervention to audit and feedback. Its behaviour change theory-informed content will allow replication of the different components and can inform future training interventions.

TRIAL REGISTRATION

ISRCTN, ISRCTN12345678 . Registered 18 June 2020.

Patient and public involvement in numerical aspects of trials: a mixed methods theory-informed survey of trialists' current practices, barriers and facilitators

OBJECTIVE

We aimed to find out if trialists involve patients and the public in numerical aspects of trials, how and what are the barriers and facilitators to doing it.

DESIGN

We developed a survey based on the Theoretical Domains Framework. We used a mixed methods approach to analyse the data and to identify important domains.

SETTING

Online survey targeting UK-based trial units.

PARTICIPANTS

Stakeholders working in UK-based clinical trials, 18 years old or over, understand English and agree to take part in the study.

OUTCOME MEASURES

Trialists' behaviour of involving patients and the public in numerical aspects of trials and its determinants.

RESULTS

We included 187 respondents. Majority were female (70%), trial managers (67%) and involved public and patient partners in numerical aspects of trials (60%). We found lack of knowledge, trialists' perception of public and patient partners' skills, capabilities and motivations, scarce resources, lack of reinforcement, and lack of guidance were barriers to involving public and patient partners in numerical aspects of trials. Positive beliefs about consequences were an incentive to doing it.

CONCLUSIONS

More training, guidance and funding can help trialists involve patient and public partners in numerical aspects, although they were uncertain about public and patient partners' motivation to be involved. Future research should focus on identifying public and patient partners' motivations and develop strategies to improve the communication of numerical aspects.

The influence of a ban on outpatient intravenous antibiotic therapy among the secondary and tertiary hospitals in China

BACKGROUND

Antimicrobial resistance (AMR) is a serious global public health challenge. Physicians' over-prescription of antibiotics is a major contributor, and intravenous (IV) antibiotic use has been a particular concern in China. To address the rapid fallout of antibiotic overuse, the Chinese government has piloted a ban of IV antibiotics in the outpatient department (OD) with the exemption of paediatrics, emergency department (ED), and inpatient ward of secondary and tertiary hospitals in several provinces.

METHODS

To assess the potential impact of the policy, we conducted a mixed-methods study including 1) interviews about the ban of IV antibiotic use with 68 stakeholders, covering patients, health workers, and policy-makers, from two cities and 2) a hospital case study which collected routine hospital data and survey data with 207 doctors.

RESULTS

Our analyses revealed that the ban of IV antibiotics in the OD led to a reduction in the total and IV antibiotic prescriptions and improved the rational antibiotic prescribing practice in the OD. Nevertheless, the policy has diverted patient flow from OD to ED, inpatient ward, and primary care for IV antibiotic prescriptions. We also found that irrational antibiotic use in paediatrics was neglected. Radical policy implementation, doctors circumvented the regulations, and lack of doctor-patient communication during patient encounters were barriers to the implementation of the ban.

CONCLUSIONS

Future efforts may include 1) to de-escalate both oral and IV antibiotic therapy in paediatric and reduce oral antibiotic therapy among adults in outpatient clinics, 2) to reduce unnecessary referrals by OD doctors to ED, primary care, or inpatient services and better coordinate for patients who clinically need IV antibiotics, 3) to incorporate demand-side tailored measures, such as public education campaigns, and 4) to improve doctor-patient communication. Future research is needed to understand how primary care and other community clinics implement the ban.

Clinician and Patient Factors Influencing Treatment Decisions: Ethnographic Study of Antibiotic Prescribing and Operative Procedures in Out-of-Hours and General Dental Practices

Operative treatment is indicated for most toothache/dental abscesses, yet antibiotics instead of procedures are often prescribed. This ethnographic study aimed to identify clinician and patient factors influencing urgent dental care for adults during actual appointments; and to identify elements sensitive to context. Appointments were observed in out-of-hours and general dental practices. Follow-up interviews took place with dentists, dental nurses, and patients. Dentist and patient factors were identified through thematic analysis of observation records and appointment/interview transcripts. Dentist factors were based on a published list of factors influencing antibiotic prescribing for adults with acute conditions across primary health care and presented within the Capability-Opportunity-Motivation-Behaviour model. Contextually sensitive elements were revealed by comparing the factors between settings. In total, thirty-one dentist factors and nineteen patient factors were identified. Beliefs about antibiotics, goals for the appointment and access to dental services were important for both dentists and patients. Dentist factors included beliefs about the lifetime impact of urgent dental procedures on patients. Patient factors included their communication and negotiation skills. Contextual elements included dentists’ concerns about inflicting pain on regular patients in general dental practice; and patients’ difficulties accessing care to complete temporary treatment provided out of hours. This improved understanding of factors influencing shared decisions about treatments presents significant opportunity for new, evidence-based, contextually sensitive antibiotic stewardship interventions.

A systematic review using the Theoretical Domains Framework to identify barriers and facilitators to the adoption of prescribing guidelines

Objectives

Evidence-based guidelines have the potential to reduce variation and increase prescribing quality. Identifying the key determinants to their uptake, using a theory-based approach, may assist in the design of successful interventions to increase their adoption into practice. This systematic review investigated barriers and facilitators identified using the Theoretical Domains Framework (TDF) to the implementation of prescribing guidelines.

Methods

Electronic databases (EMBASE, PubMed) were searched. Studies were included if they used the TDF to identify key determinants of guideline implementation. Only studies published in English were included.

Key findings

Of the 407 studies identified, 15 were included. A range of patient populations and therapeutic categories were represented. Multiple determinants were identified that affected guideline implementation, with similarities and differences identified across studies. Barriers to guideline adoption included time restriction, lack of awareness, guideline complexity, lack of clinical evidence, social influences and disagreement. Facilitators included peer influence, guideline simplicity, confidence and belief about the positive consequences derived from guideline adoption, for examples improved care and patient outcomes.

Conclusions

Multiple behavioural factors affect the adoption of prescribing guidelines. The results aided the understanding of factors that may be targeted to increase guideline compliance. However, barriers and facilitators can vary significantly in different environments; therefore, research that targets particular healthcare settings and patient populations may provide further evidence to increase the specificity and credibility of intervention strategies.

Using big data to promote precision oral health in the context of a learning healthcare system

There has been a call for evidence-based oral healthcare guidelines, to improve precision dentistry and oral healthcare delivery. The main challenges to this goal are the current lack of up-to-date evidence, the limited integrative analytical data sets, and the slow translations to routine care delivery. Overcoming these issues requires knowledge discovery pipelines based on big data and health analytics, intelligent integrative informatics approaches, and learning health systems. This article examines how this can be accomplished by utilizing big data. These data can be gathered from four major streams: patients, clinical data, biological data, and normative data sets. All these must then be uniformly combined for analysis and modelling and the meaningful findings can be implemented clinically. By executing data capture cycles and integrating the subsequent findings, practitioners are able to improve public oral health and care delivery.

The Psychological Models of Health-related Behavior in Understanding Sugars Intake in Adults: A Review

Free sugars intake plays a major role in dental caries formation and other general health issues such as obesity. Therefore, interventions, which assist individuals or populations in the control of their free sugars intake, are of central importance in caries prevention strategies. There is good evidence that behavioral interventions benefit from a foundation in conceptual theories of behavior change founded on empirical data. In this review, we discuss the future application of seven theories, including six common psychological theories in predicting and developing interventions to reduce free sugars intake related to dental caries among adults. For each model, we summarize its key features and the data derived from its application in general and oral health settings and make recommendations for future research. We searched Medline, PsycINFO, Global Health, PubMed, and Embase databases to identify items dealing with dental caries, adults, sugars intake, and six psychological theories. These included the Transtheoretical Model of Change, Theory of Planned Behavior, Social Cognitive Theory, Information-Motivation-Behavioral Skills model, PRIME Theory, and Behavior Change Wheel theories. We searched literature published in the last 10 years, and priority was given to systematic reviews and randomized control trials. Although there is extensive literature on the application of the six psychological theories, there is a gap in knowledge about their effectiveness in reducing free sugars intake related to dental caries among adults. There is a need for better-designed trials of interventions based on the clear operationalization of psychological constructs to reduce sugars intake among the adult population.

Driving sustainable change in antimicrobial prescribing practice: how can social and behavioural sciences help?

Addressing the growing threat of antimicrobial resistance is, in part, reliant on the complex challenge of changing human behaviour-in terms of reducing inappropriate antibiotic use and preventing infection. Whilst there is no 'one size fits all' recommended behavioural solution for improving antimicrobial stewardship, the behavioural and social sciences offer a range of theories, frameworks, methods and evidence-based principles that can help inform the design of behaviour change interventions that are context-specific and thus more likely to be effective. However, the state-of-the-art in antimicrobial stewardship research and practice suggests that behavioural and social influences are often not given due consideration in the design and evaluation of interventions to improve antimicrobial prescribing. In this paper, we discuss four potential areas where the behavioural and social sciences can help drive more effective and sustained behaviour change in antimicrobial stewardship: (i) defining the problem in behavioural terms and understanding current behaviour in context; (ii) adopting a theory-driven, systematic approach to intervention design; (iii) investigating implementation and sustainability of interventions in practice; and (iv) maximizing learning through evidence synthesis and detailed intervention reporting.

Antibiotic resistance and antibiotic prescribing by dentists in England 2007-2016

The early prescribers of penicillin realised that antibiotics should be used wisely and as an adjunct to traditional surgical provision. They predicted that inappropriate use would increase sensitisation to the drug. National Health Service dentists prescribed almost 10% of antibiotics issued in NHS general practice in 2016 and an audit shows that many of these may have been prescribed inappropriately. One of the causes of antimicrobial resistance is over prescription of the drugs. This paper recalls the recommendations of some early users of penicillin, reports on the current prescription patterns of dentists in England, describes the mechanism of acquisition of anti-microbial resistance and discusses dentists' role in attempting to reduce the problem.

Factors associated with antibiotic prescribing for adults with acute conditions: an umbrella review across primary care and a systematic review focusing on primary dental care

INTRODUCTION

One way to slow the spread of resistant bacteria is by improved stewardship of antibiotics: using them more carefully and reducing the number of prescriptions. With an estimated 7%-10% of antibiotic prescriptions globally originating from dental practices and up to 80% prescribed unnecessarily, dentistry has an important role to play. To support the design of new stewardship interventions through knowledge transfer between contexts, this study aimed to identify factors associated with the decision to prescribe antibiotics to adults presenting with acute conditions across primary care (including dentistry).

METHODS

Two reviews were undertaken: an umbrella review across primary healthcare and a systematic review in dentistry. Two authors independently selected and quality assessed the included studies. Factors were identified using an inductive thematic approach and mapped to the Theoretical Domains Framework (TDF). Comparisons between dental and other settings were explored. Registration number: PROSPERO_CRD42016037174.

RESULTS

Searches identified 689 publications across primary care and 432 across dental care. Included studies (nine and seven, respectively) were assessed as of variable quality. They covered 46 countries, of which 12 were low and middle-income countries (LMICs). Across the two reviews, 30 factors were identified, with 'patient/condition characteristics', 'patient influence' and 'guidelines & information' the most frequent. Two factors were unique to dental studies: 'procedure possible' and 'treatment skills'. No factor related only to LMICs.

CONCLUSIONS

A comprehensive list of factors associated with antibiotic prescribing to adults with acute conditions in primary care settings around the world has been collated and should assist theory-informed design of new context-specific stewardship interventions.

Examining influences on antibiotic prescribing by nurse and pharmacist prescribers: a qualitative study using the Theoretical Domains Framework and COM-B

OBJECTIVES

Respiratory tract infections are frequently managed by nurse and pharmacist prescribers, and these prescribers are responsible for 8% of all primary care antibiotic prescriptions. Few studies have explored antibiotic prescribing among these prescribers, and interventions to target their antibiotic prescribing behaviour do not exist. Research objectives were to: (1) use the Theoretical Domains Framework to identify the factors that influence nurse and pharmacist prescriber management of respiratory tract infections and (2) identify the behaviour change techniques (BCTs) that can be used as the basis for the development of a theoretically informed intervention to support appropriate prescribing behaviour.

DESIGN

Qualitative design comprising semistructured interviews, using the Theoretical Domains Framework and Capability, Opportunity and Motivation for Behaviour.

SETTING

Primary care.

PARTICIPANTS

Twenty one prescribers (4 pharmacists and 17 nurses).

RESULTS

A range of factors across 12 domains of the TDF were found to influence prescriber behaviour, and 40 BCTs were identified as supporting appropriate prescribing. For example, patient expectations (social influence) was identified as a factor influencing prescribing decisions, and a number of BCTs (problem solving, goal setting and information about health consequences) were identified as supporting prescribers in managing these expectations.

CONCLUSION

With increasing numbers of nurse and pharmacist prescribers managing infections in primary care, these findings will inform theoretically grounded interventions to support appropriate prescribing behaviour by these groups.

How Should We Evaluate and Use Evidence to Improve Population Oral Health?

Generating and implementing evidence-based policy is an important aim for many publicly funded health systems. In dentistry, this is based on the assumption that evidence-based health care increases the efficiency and effectiveness of interventions to improve oral health at a population level. This article argues that a linear logic model that links the generation of research evidence with its use is overly simplistic. It also challenges an uncritical interpretation of the evidence-based paradigm and explores approaches to the evaluation of complex interventions and how they can be embedded into policy and practice to improve oral health at a population level.

A theory-informed assessment of the barriers and facilitators to nurse-driven antimicrobial stewardship

BACKGROUND

Nurses represent an underused workforce for performing antimicrobial stewardship (AMS) activities. Before engaging nurses in these activities, barriers and facilitators to the targeted behavior change should be identified using a validated model.

METHODS

This was a prospective, qualitative, descriptive study to determine the barriers and facilitators to the promotion of intravenous (IV) to oral (PO) antimicrobials by nurses. Semi-structured 1-on-1 interviews of nurses were conducted from January-February 2017. Interviews were analyzed for themes within the domains of the theoretical domains framework (TDF) by directed-content analysis.

RESULTS

Evaluation of the 14 TDF domains revealed 9 modifiable barriers to nurse promotion of IV to PO step-down, including insufficient knowledge, lack of prescriber cooperation, lack of self-confidence, and low priority activity. Nine facilitators that could enhance nurse promotion of step-down were identified, including capability to assess patients for step-down, ability to communicate assessment results to the team, and preexistence of a variety of resources available for nurse education and training. Nurses perceived that increased step-down rates would increase nursing efficiency.

CONCLUSIONS

Nurses have the potential to improve AMS through promotion of IV to PO step-down of antimicrobials. Themes pertaining to barriers and facilitators of nurses' participation in IV to PO step-down of antimicrobials were identified.

Knowledge and attitudes of recently qualified dentists working in Wales towards antimicrobial prescribing and resistance

AIMS

To discover newly qualified dentists' confidence towards prescribing antimicrobials and explore their attitudes concerning the emergence of antimicrobial resistance (AMR).

MATERIALS AND METHODS

This was a cross-sectional study; questionnaires exploring attitudes towards issues related to antimicrobial use and resistance were distributed to dentists undergoing Dental Foundation (DF), Dental Core (DC) or Longitudinal Dental Foundation Training in Wales.

RESULTS

A total of 71 of 90 questionnaires were returned, giving a response rate of 78.9%. Most respondents (90.0%) agreed that antimicrobial resistance poses a serious threat to public health in the UK and 78.9% reported that they considered the impact of dental prescribing to the emergence of resistance to be moderate or greater. The greatest influences on prescribing behaviour were the use of guidelines and teaching received as an undergraduate. Although the majority of participants agreed that they had sufficient training in antimicrobial prescribing, some were not confident when issuing a prescription or undertaking operative treatment for patients with acute dental conditions. Many reported that their prescribing behaviours were influenced by additional pressures, such as if operative treatment had to be delayed. The majority (77.5%) agreed that changes should be implemented to optimise dentists' antimicrobial prescribing practices, such as increasing the availability of clinical guidelines or further teaching at undergraduate level.

DISCUSSION AND CONCLUSIONS

Undergraduate dental curricula should include specific competencies relating to antimicrobial use and factors contributing to the development of antimicrobial resistance.

The use and misuse of antibiotics in dentistry: A scoping review

BACKGROUND

To describe antibiotic prescribing behaviors in dentistry, including clinical and nonclinical indications for their use, the type and regimen of antibiotics prescribed, and factors influencing their prescription, the authors conducted a scoping review.

TYPES OF STUDIES REVIEWED

The authors conducted a scoping review of published literature by searching multiple databases. Key search terms included dentist, antibiotic, antimicrobial, antibacterial, prophylaxis, prescription, pattern, habit, knowledge, and practice. Two authors independently reviewed titles and abstracts by using detailed eligibility criteria. The authors placed no restrictions on study design or publication year. The authors qualitatively assessed studies by using a modified version of the Center for Evidence-Based Management's critical appraisal of a survey checklist.

RESULTS

The authors identified 1,912 studies but considered only 118 studies eligible for review. Most included studies were either cross-sectional surveys (81 studies) or prescription audits (25 studies) from various geographic locations. Publication dates ranged from 1982 through 2017. The authors examined prophylactic and therapeutic antibiotic use in 48 and 29 studies, respectively. Another 29 studies examined the use of both prophylactic and therapeutic antibiotics in dentistry. Overall, dentists prescribed a wide variety of antibiotic regimens for various clinical and nonclinical indications. Dentists have acquired their prescribing knowledge from a variety of sources and have changed their antibiotic prescribing practices throughout their careers for various reasons.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Considering the seriousness of antibiotic resistance, the authors highlight trends in antibiotic prescribing practices, characterize factors contributing to the use and misuse of antibiotics in dentistry, provide insight into the importance of antibiotic stewardship in the oral health setting, and encourage dentists to reflect on their antibiotic prescription practices.

Dentists' prescribing of antibiotics and opioids to Medicare Part D beneficiaries: Medications of high impact to public health

BACKGROUND

Gaining a better understanding of dental prescribing can help identify opportunities for intervention regarding optimal medication use. The purpose of this study is to characterize opioid and antibiotic prescribing patterns of dentists in the United States for Medicare Part D beneficiaries.

METHODS

The authors conducted a retrospective cross-sectional analysis of national 2014 Medicare Part D Prescriber Public Use File data. Providers in the data set with dental-related disciplines were included (n = 99,797). Outcomes of interest were mean days' supply and mean number of claims reported per claim, beneficiary, and prescriber discipline.

RESULTS

Of the 6,724,372 dental prescription claims submitted, 3,947,848 (58.7%) and 1,312,796 (19.5%) were for antibiotics and opioids, respectively. Sixty-nine percent of dentists in the highest quartile of opioid prescribers were also in the highest quartile of antibiotic prescribers (r² = 0.7778; P < .01). The mean (standard deviation) days' supply per claim was 6.9 (5.3) days (range, 1-90 days) for antibiotics and 3.6 (2.0) days (range, 1-44.5 days) for opioids. Of the 33,348 dental providers who prescribed opioids, 18,971 (56.9%) prescribed a mean opioid days per claim greater than the recommended duration of 3 days for acute pain.

CONCLUSION

Opioids and antibiotics are the medications most prescribed by dentists. On the basis of national recommendations and results of studies from other countries, the length of therapy prescribed may be excessive. Further studies should be conducted to assess appropriateness of dental prescriptions.

PRACTICAL IMPLICATIONS

Dentistry should be considered for antibiotic and opioid stewardship interventions along with medicine.

Observance of Sterilization Protocol Guideline Procedures of Critical Instruments for Preventing Iatrogenic Transmission of Creutzfeldt-Jakob Disease in Dental Practice in France, 2017

Effective sterilization of reusable instruments contaminated by Creutzfeldt–Jakob disease in dental care is a crucial issue for public health. The present cross-sectional study investigated how the recommended procedures for sterilization were implemented by French dental practices in real-world settings. A sample of dental practices was selected in the French Rhône-Alpes region. Data were collected by a self-questionnaire in 2016. Sterilization procedures (n = 33) were classified into 4 groups: (1) Pre-sterilization cleaning of reusable instruments; (2) Biological verification of sterilization cycles—Monitoring steam sterilization procedures; (3) Autoclave performance and practitioner knowledge of autoclave use; (4) Monitoring and documentation of sterilization procedures—Tracking and tracing the instrumentation. Answers were provided per procedure, along with the global implementation of procedures within a group (over 80% correctly performed). Then it was verified how adherence to procedure groups varied with the size of the dental practice and the proportion of dental assistants within the team. Among the 179 questionnaires available for the analyses, adherence to the recommended procedures of sterilization noticeably varied between practices, from 20.7% to 82.6%. The median percentages of procedures correctly implemented per practice were 58.1%, 50.9%, 69.2% and 58.2%, in Groups 1, 2, 3 and 4, respectively (corresponding percentages for performing over 80% of the procedures in the group: 23.4%, 6.6%, 46.6% and 38.6%). Dental practices ≥ 3 dental units performed significantly better (>80%) procedures of Groups 2 and 4 (p = 0.01 and p = 0.002, respectively), while no other significant associations emerged. As a rule, practices complied poorly with the recommended procedures, despite partially improved results in bigger practices. Specific training regarding sterilization procedures and a better understanding of the reasons leading to their non-compliance are needed.

Opportunities and challenges to improving antibiotic prescribing practices through a One Health approach: results of a comparative survey of doctors, dentists and veterinarians in Australia

OBJECTIVES

To explore and compare the knowledge, attitudes and experiences of doctors, dentists and veterinarians (as prescribers) in relation to antibiotic use and antibiotic resistance (AbR), and to consider the implications of these for policy-making that support a One Health approach.

DESIGN

A cross-sectional survey conducted online.

SETTING

Doctors, dentists and veterinarians practising in primary, secondary or tertiary care in Australia.

PARTICIPANTS

547 doctors, 380 dentists and 403 veterinarians completed the survey.

MAIN OUTCOME MEASURES

Prescribers' knowledge, attitudes and perceptions of AbR, the extent to which a range of factors are perceived as barriers to appropriate prescribing practices, and perceived helpfulness of potential strategies to improve antibiotic prescribing in practice.

RESULTS

There was substantial agreement across prescriber groups that action on AbR is required by multiple sectors and stakeholders. However, prescribers externalised responsibility to some extent by seeing the roles of others as more important than their own in relation to AbR. There were common and context-specific barriers to optimal prescribing across the prescriber groups. Prescriber groups generally perceived restrictive policies as unhelpful to supporting appropriate prescribing in their practice.

CONCLUSIONS

The results have implications for implementing a One Health approach that involves doctors, dentists and veterinarians as key players to tackling the crisis of AbR. The findings are that (1) prescribers understand and are likely receptive to a One Health policy approach to AbR, (2) policy development should be sensitive to barriers that are specific to individual prescriber groups and (3) the development and introduction of interventions that might be perceived as reducing prescriber autonomy will need to be carefully designed and implemented.

Barriers and facilitators for the management of vertigo: a qualitative study with primary care providers

Background

Although the management of patients presenting with vertigo and dizziness in primary care has been reported to be inefficient, little is known about the primary care providers’ (PCPs) perspectives, needs, and attitudes regarding vertigo management.

The objective of this study was to understand which challenges and barriers PCPs see when diagnosing and treating patients presenting with vertigo or dizziness. Specifically, we wanted to identify facilitators and barriers of successful guideline implementation in order to inform the development of targeted interventions.

Methods

A theory-based interview structure was developed based on the implementation theory of capability, opportunity, and motivation for behaviour change (COM-B) using questions based on constructs from the Theoretical Domains Framework (TDF) and the Consolidated Framework for Implementation Research (CFIR). Transcripts of the semi-structured interviews were analysed using directed content analysis. The pathways through which guideline characteristics and supportive interventions affect the relationship between the PCPs’ perceived capability, opportunity, and motivation as well as their practice of managing vertigo patients were graphically presented using the COM-B model structure.

Results

Twelve PCPs from Bavaria in Southern Germany participated in semi-structured interviews. Diagnostics posed the biggest challenge in vertigo management to the PCPs. Requirements for an acceptable guideline were stakeholder involvement in the development process, clarity of presentation, and high applicability. Guideline implementation might be effectively supported through educational meetings and sustained by organisational interventions.

Conclusions

From the PCPs’ perspective, both guideline characteristics and interventions supporting guideline implementation may help resolve challenges in vertigo management in primary care. These results should be used to guide future interventions in the primary care setting to ensure successful and targeted patient management.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0716-y) contains supplementary material, which is available to authorized users.

An evaluation of dental antibiotic prescribing practices in the United States

BACKGROUND

Antibiotic prescribing practices among general dentists and dental specialists in the United States remains poorly understood. The purpose of this study was to compare prescribing practices across dental specialties, evaluate the duration of antibiotics dentists prescribed, and determine variation in antibiotic selection among dentists.

METHODS

The authors performed a retrospective cross-sectional analysis of dental care provider specialties linked to deidentified antibiotic claims data from a large pharmacy benefits manager during the 2015 calendar year.

RESULTS

As a group, general dentists and dental specialists were responsible for more than 2.9 million antibiotic prescriptions, higher than levels for several other medical and allied health care provider specialties. Antibiotic treatment duration generally was prolonged and commonly included broad-spectrum agents, such as amoxicillin clavulanate and clindamycin. Although amoxicillin was the most commonly prescribed antibiotic among all dental specialties, there was substantial variation among other antibiotics each specialty selected. The most common antibiotic treatment durations were 7 and 10 days.

CONCLUSIONS

This study's results demonstrate that dentists frequently prescribe antibiotics for prolonged periods and often use broad-spectrum antibiotics. Further studies are necessary to evaluate the appropriateness of these antibiotic prescribing patterns.

PRACTICAL IMPLICATIONS

The clinically significant variation in antibiotic selection and treatment duration identified among all dental specialties in this study population implies that further research and guidance into the treatment of dental infections is necessary to improve and standardize antibiotic prescribing practices.

What factors influence uptake of retinal screening among young adults with type 2 diabetes? A qualitative study informed by the theoretical domains framework

AIMS

Young adults with type 2 diabetes (T2D, 18-39years) face increased risk of vision loss from diabetic retinopathy (DR). Retinal screening is essential to detect DR, yet screening rates for this group are low and little is known about the underlying factors influencing this important behavior. Using the theoretical domains framework (TDF) to guide data collection and analysis, we explored screening barriers and facilitator, contrasting them with a comparator group of older adults with T2D (40+ years).

METHODS

Thirty semi-structured telephone interviews (10 younger, 20 older adults) were conducted. Data were coded into TDF domains with salience identified by "frequency" of reference. Screening facilitators and barriers were systematically compared between groups.

RESULTS

Although many screening facilitators and barriers were shared by younger and older adults, additional factors highly relevant to the former included: social comparison with others ('social influences'); concern for the impact on the family unit, unrealistic optimism and perceived invulnerability ('beliefs about consequences'); lack of time and financial resources ('environmental context and resources'), and DR misconceptions ('knowledge').

CONCLUSIONS

This study demonstrated that young adult retinal screening behavior was influenced by additional social cognitive factors compared to older adults, providing a first-step evidence base for clinicians and other health professionals, and potential targets for future eye health and retinal screening interventions.

Using theory to explore facilitators and barriers to delayed prescribing in Australia: a qualitative study using the Theoretical Domains Framework and the Behaviour Change Wheel

BACKGROUND

Delayed antibiotic prescribing reduces antibiotic use for acute respiratory infections in trials in general practice, but the uptake in clinical practice is low. The aim of the study was to identify facilitators and barriers to general practitioners' (GPs') use of delayed prescribing and to gain pharmacists' and the public's views about delayed prescribing in Australia.

METHODS

This study used the Theoretical Domains Framework and the Behaviour Change Wheel to explore facilitators and barriers to delayed prescribing in Australia. Forty-three semi-structured, face-to-face interviews with general practitioners, pharmacists and patients were conducted. Responses were coded into domains of the Theoretical Domains Framework, and specific criteria from the Behaviour Change Wheel were used to identify which domains were relevant to increasing the use of delayed prescribing by GPs.

RESULTS

The interviews revealed nine key domains that influence GPs' use of delayed prescribing: knowledge; cognitive and interpersonal skills; memory, attention and decision-making processes; optimism; beliefs about consequences; intentions; goals; emotion; and social influences: GPs knew about delayed prescribing; however, they did not use it consistently, preferring to bring patients back for review and only using it with patients in a highly selective way. Pharmacists would support GPs and the public in delayed prescribing but would fill the prescription if people insisted. The public said they would delay taking their antibiotics if asked by their GP and given the right information on managing symptoms and when to take antibiotics.

CONCLUSIONS

Using a theory-driven approach, we identified nine key domains that influence GPs' willingness to provide a delayed prescription to patients with an acute respiratory infection presenting to general practice. These data can be used to develop a structured intervention to change this behaviour and thus reduce antibiotic use for acute respiratory infections in general practice.

Combined use of the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF): a systematic review

Background

Over 60 implementation frameworks exist. Using multiple frameworks may help researchers to address multiple study purposes, levels, and degrees of theoretical heritage and operationalizability; however, using multiple frameworks may result in unnecessary complexity and redundancy if doing so does not address study needs. The Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF) are both well-operationalized, multi-level implementation determinant frameworks derived from theory. As such, the rationale for using the frameworks in combination (i.e., CFIR + TDF) is unclear. The objective of this systematic review was to elucidate the rationale for using CFIR + TDF by (1) describing studies that have used CFIR + TDF, (2) how they used CFIR + TDF, and (2) their stated rationale for using CFIR + TDF.

Methods

We undertook a systematic review to identify studies that mentioned both the CFIR and the TDF, were written in English, were peer-reviewed, and reported either a protocol or results of an empirical study in MEDLINE/PubMed, PsycInfo, Web of Science, or Google Scholar. We then abstracted data into a matrix and analyzed it qualitatively, identifying salient themes.

Findings

We identified five protocols and seven completed studies that used CFIR + TDF. CFIR + TDF was applied to studies in several countries, to a range of healthcare interventions, and at multiple intervention phases; used many designs, methods, and units of analysis; and assessed a variety of outcomes. Three studies indicated that using CFIR + TDF addressed multiple study purposes. Six studies indicated that using CFIR + TDF addressed multiple conceptual levels. Four studies did not explicitly state their rationale for using CFIR + TDF.

Conclusions

Differences in the purposes that authors of the CFIR (e.g., comprehensive set of implementation determinants) and the TDF (e.g., intervention development) propose help to justify the use of CFIR + TDF. Given that the CFIR and the TDF are both multi-level frameworks, the rationale that using CFIR + TDF is needed to address multiple conceptual levels may reflect potentially misleading conventional wisdom. On the other hand, using CFIR + TDF may more fully define the multi-level nature of implementation. To avoid concerns about unnecessary complexity and redundancy, scholars who use CFIR + TDF and combinations of other frameworks should specify how the frameworks contribute to their study.

Trial registration

PROSPERO CRD42015027615

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0534-z) contains supplementary material, which is available to authorized users.

An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial

BACKGROUND

Dentists prescribe approximately 10% of antibiotics dispensed in UK community pharmacies. Despite clear clinical guidance, dentists often prescribe antibiotics inappropriately. This cluster-randomised controlled trial used routinely collected National Health Service (NHS) dental prescribing and treatment claim data to compare the impact of individualised audit and feedback (A&F) interventions on dentists' antibiotic prescribing rates.

METHODS AND FINDINGS

All 795 antibiotic prescribing NHS general dental practices in Scotland were included. Practices were randomised to the control (practices = 163; dentists = 567) or A&F intervention group (practices = 632; dentists = 1,999). A&F intervention practices were allocated to one of two A&F groups: (1) individualised graphical A&F comprising a line graph plotting an individual dentist's monthly antibiotic prescribing rate (practices = 316; dentists = 1,001); or (2) individualised graphical A&F plus a written behaviour change message synthesising and reiterating national guidance recommendations for dental antibiotic prescribing (practices = 316; dentists = 998). Intervention practices were also simultaneously randomised to receive A&F: (i) with or without a health board comparator comprising the addition of a line to the graphical A&F plotting the monthly antibiotic prescribing rate of all dentists in the health board; and (ii) delivered at 0 and 6 mo or at 0, 6, and 9 mo, giving a total of eight intervention groups. The primary outcome, measured by the trial statistician who was blinded to allocation, was the total number of antibiotic items dispensed per 100 NHS treatment claims over the 12 mo post-delivery of the baseline A&F. Primary outcome data was available for 152 control practices (dentists = 438) and 609 intervention practices (dentists = 1,550). At baseline, the number of antibiotic items prescribed per 100 NHS treatment claims was 8.3 in the control group and 8.5 in the intervention group. At follow-up, antibiotic prescribing had decreased by 0.4 antibiotic items per 100 NHS treatment claims in control practices and by 1.0 in intervention practices. This represents a significant reduction (-5.7%; 95% CI -10.2% to -1.1%; p = 0.01) in dentists' prescribing rate in the intervention group relative to the control group. Intervention subgroup analyses found a 6.1% reduction in the antibiotic prescribing rate of dentists who had received the written behaviour change message relative to dentists who had not (95% CI -10.4% to -1.9%; p = 0.01). There was no significant between-group difference in the prescribing rate of dentists who received a health board comparator relative to those who did not (-4.3%; 95% CI -8.6% to 0.1%; p = 0.06), nor between dentists who received A&F at 0 and 6 mo relative to those who received A&F at 0, 6, and 9 mo (0.02%; 95% CI -4.2% to 4.2%; p = 0.99). The key limitations relate to the use of routinely collected datasets which did not allow evaluation of any effects on inappropriate prescribing.

CONCLUSIONS

A&F derived from routinely collected datasets led to a significant reduction in the antibiotic prescribing rate of dentists.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49204710.