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Albahar F, Abu-Farha RK, Alshogran OY, Alhamad H, Curtis CE, Marriott JF. Healthcare Professionals’ Perceptions, Barriers, and Facilitators towards Adopting Computerised Clinical Decision Support Systems in Antimicrobial Stewardship in Jordanian Hospitals. Healthcare (Basel) 2023; 11:healthcare11060836. [PMID: 36981493 PMCID: PMC10047934 DOI: 10.3390/healthcare11060836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/24/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
Understanding healthcare professionals’ perceptions towards a computerised decision support system (CDSS) may provide a platform for the determinants of the successful adoption and implementation of CDSS. This cross-sectional study examined healthcare professionals’ perceptions, barriers, and facilitators to adopting a CDSS for antibiotic prescribing in Jordanian hospitals. This study was conducted among healthcare professionals in Jordan’s two tertiary and teaching hospitals over four weeks (June–July 2021). Data were collected in a paper-based format from senior and junior prescribers and non-prescribers (n = 254) who agreed to complete a questionnaire. The majority (n = 184, 72.4%) were aware that electronic prescribing and electronic health record systems could be used specifically to facilitate antibiotic use and prescribing. The essential facilitator made CDSS available in a portable format (n = 224, 88.2%). While insufficient training to use CDSS was the most significant barrier (n = 175, 68.9%). The female providers showed significantly lower awareness (p = 0.006), and the nurses showed significantly higher awareness (p = 0.041) about using electronic prescribing and electronic health record systems. This study examined healthcare professionals’ perceptions of adopting CDSS in antimicrobial stewardship (AMS) and shed light on the perceived barriers and facilitators to adopting CDSS in AMS, reducing antibiotic resistance, and improving patient safety. Furthermore, results would provide a framework for other hospital settings concerned with implementing CDSS in AMS and inform policy decision-makers to react by implementing the CDSS system in Jordan and globally. Future studies should concentrate on establishing policies and guidelines and a framework to examine the adoption of the CDSS for AMS.
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Affiliation(s)
- Fares Albahar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Zarqa University, P.O. Box 2000, Zarqa 13110, Jordan
- Correspondence:
| | - Rana K. Abu-Farha
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, P.O. Box 541350, Amman 11937, Jordan
| | - Osama Y. Alshogran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan
| | - Hamza Alhamad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Zarqa University, P.O. Box 2000, Zarqa 13110, Jordan
| | - Chris E. Curtis
- Department of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - John F. Marriott
- Department of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
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Paediatric Antimicrobial Stewardship for Respiratory Infections in the Emergency Setting: A Systematic Review. Antibiotics (Basel) 2021; 10:antibiotics10111366. [PMID: 34827304 PMCID: PMC8615165 DOI: 10.3390/antibiotics10111366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022] Open
Abstract
Antimicrobial resistance occurs due to the propensity of microbial pathogens to develop resistance to antibiotics over time. Antimicrobial stewardship programs (ASPs) have been developed in response to this growing crisis, to limit unnecessary antibiotic prescription through initiatives such as education-based seminars, prescribing guidelines, and rapid respiratory pathogen (RRP) testing. Paediatric patients who present to the emergency setting with respiratory symptoms are a particularly high-risk population susceptible to inappropriate antibiotic prescribing behaviours and are therefore an ideal cohort for focused ASPs. The purpose of this systematic review was to assess the efficacy and safety of ASPs in this clinical context. A systematic search of PubMed, Medline, EMBASE and the Cochrane Database of Systematic Reviews was conducted to review the current evidence. Thirteen studies were included in the review and these studies assessed a range of stewardship interventions and outcome measures. Overall, ASPs reduced the rates of antibiotic prescription, increased the prescription of narrow-spectrum antibiotics, and shortened the duration of antibiotic therapy. Multimodal interventions that were education-based and those that used RRP testing were found to be the most effective. Whilst we found strong evidence that ASPs are effective in reducing antibiotic prescribing, further studies are required to assess whether they translate to equivalent clinical outcomes.
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Barriers and facilitators influencing medication-related CDSS acceptance according to clinicians: A systematic review. Int J Med Inform 2021; 152:104506. [PMID: 34091146 DOI: 10.1016/j.ijmedinf.2021.104506] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/20/2021] [Accepted: 05/18/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND A medication-related Clinical Decision Support System (CDSS) is an application that analyzes patient data to provide assistance in medication-related care processes. Despite its potential to improve the clinical decision-making process, evidence shows that clinicians do not always use CDSSs in such a way that their potential can be fully realized. This systematic literature review provides an overview of frequently-reported barriers and facilitators for acceptance of medication-related CDSS. MATERIALS AND METHODS Search terms and MeSH headings were developed in collaboration with a librarian, and database searches were conducted in Medline, Scopus, Embase and Web of Science Conference Proceedings. After screening 5404 records and 140 full papers, 63 articles were included in this review. Quality assessment was performed for all 63 included articles. The identified barriers and facilitators are categorized within the Human, Organization, Technology fit (HOT-fit) model. RESULTS A total of 327 barriers and 291 facilitators were identified. Results show that factors most often reported were related to (a lack of) usefulness and relevance of information, and ease of use and efficiency of the system. DISCUSSION This review provides a valuable insight into a broad range of barriers and facilitators for using a medication-related CDSS as perceived by clinicians. The results can be used as a stepping stone in future studies developing medication-related CDSSs.
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Lee TH, Lye DC, Chung DR, Thamlikitkul V, Lu M, Wong AT, Hsueh PR, Wang H, Cooper C, Wong JG, Shimono N, Pham VH, Perera J, Yang YH, Shibl AM, Kim SH, Hsu LY, Song JH. Antimicrobial stewardship capacity and manpower needs in the Asia Pacific. J Glob Antimicrob Resist 2021; 24:387-394. [PMID: 33548495 DOI: 10.1016/j.jgar.2021.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 12/03/2020] [Accepted: 01/23/2021] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES Antimicrobial stewardship is a strategy to combat antimicrobial resistance in hospitals. Given the burden and impact of antimicrobial resistance in the Asia Pacific, it is important to document capacity and gaps in antimicrobial stewardship programmes (ASP). We aimed to understand existing capacities and practices, and define the resources needed to establish antimicrobial stewardship where it is lacking. METHODS An anonymous online survey, consisting of questions on antimicrobial control at country, hospital and programme levels, was circulated to healthcare providers in the field of infectious diseases and microbiology through Asian Network for Surveillance of Resistant Pathogens, ReAct Group and the Australasian Society for infectious Diseases. RESULTS 139 participants from 16 countries or regions completed the survey. The majority of participants were adult infectious diseases physicians (61/139, 43.9%) and microbiologists (31/139, 22.3%). Participants from 7 countries reported that antimicrobials can be obtained without prescriptions. Despite the high percentage (75.5%) of respondents working in large hospitals, only 22/139 participants (15.8%) from Australia, China, Singapore, Taiwan, Thailand and Vietnam reported having more than 10 infectious diseases physicians. Hospital empiric antimicrobial guidelines for common infections were available according to 110/139 (79.1%) participants. Pre-authorisation of antimicrobials was reported by 88/113 (77.9%) respondents while prospective audit and feedback was reported by 93/114 (81.6%). Automatic stop orders and culture-guided de-escalation were reported by only 52/113 (46.0%) and 27/112 (24.1%) respectively. CONCLUSION The survey reveals a wide range of ASP development in Asia Pacific. Establishing national workgroups and guidelines will help advance antimicrobial stewardship in this diverse region.
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Affiliation(s)
- Tau Hong Lee
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore; Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - David C Lye
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore; Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Doo Ryeon Chung
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Asia Pacific Foundation for Infectious Diseases, Seoul, Republic of Korea
| | | | - Min Lu
- Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Andrew Ty Wong
- Infectious Disease Control Training Centre, Hospital Authority, Hong Kong
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hui Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Celia Cooper
- Department of Infectious Diseases, Women's and Children's Hospital, South Australia, Australia
| | - Joshua Gx Wong
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
| | - Nobuyuki Shimono
- Center for the Study of Global Infection, Kyushu University Hospital, Japan
| | - Van Hung Pham
- School of Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | - Jennifer Perera
- Department of Microbiology, Faculty of Medicine, University of Colombo, Sri Lanka
| | - Yong-Hong Yang
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Atef M Shibl
- Department of Microbiology and Immunology, College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia
| | - So Hyun Kim
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Asia Pacific Foundation for Infectious Diseases, Seoul, Republic of Korea
| | - Li Yang Hsu
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore; Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Jae-Hoon Song
- Asia Pacific Foundation for Infectious Diseases, Seoul, Republic of Korea; CHA Bio Group, Gyeonggi-do, Republic of Korea
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Abbara S, Domenech de Cellès M, Batista R, Mira JP, Poyart C, Poupet H, Casetta A, Kernéis S. Variable impact of an antimicrobial stewardship programme in three intensive care units: time-series analysis of 2012-2017 surveillance data. J Hosp Infect 2019; 104:150-157. [PMID: 31605739 DOI: 10.1016/j.jhin.2019.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/29/2019] [Accepted: 10/01/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preprescription authorization (PPA) and postprescription review with feedback (PPRF) were successively implemented in 2012 and 2016 in our 1500-bed hospital. AIM The impact of PPA and PPRF on carbapenems use and resistance levels of Pseudomonas aeruginosa was assessed in three intensive care units (ICUs). METHODS Carbapenems use (in DDDs/1000 occupied bed-days) and resistance of P. aeruginosa (percentage of non-susceptible (I+R) isolates to imipenem and/or meropenem) were analysed using a controlled interrupted time-series method. Two periods were compared: 2012-2015 (PPA) and 2016-2017 (PPA+PPRF). Models were adjusted on the annual incidence of extended-spectrum β-lactamase-producing enterobacteriacae. FINDINGS Carbapenem use was stable over the PPA period in all ICUs, with a significant change of slope over the PPA+PPRF period only in ICU1 (β2 = -12.8, 95% confidence interval (CI) = -19.5 to -6.1). There was a switch from imipenem to meropenem during the PPA period in all three units. Resistances of P. aeruginosa were stable over the study period in ICU1 and ICU2, and significantly decreased over the PPA+PPRF period in ICU3 (β2 = -0.18, CI = -0.3 to -0.03). CONCLUSION In real-life conditions and with the same antimicrobial stewardship programme (AMSP) led by a single team, the impact of PPRF was heterogeneous between ICUs. Factors driving the impact of AMSPs should be further assessed in comparable settings through real-life data, to target where they could prove cost-effective.
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Affiliation(s)
- S Abbara
- INSERM, UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology, and Infectious Diseases (B2PHI), Paris, France; Institut Pasteur, B2PHI, Paris, France; Versailles Saint-Quentin University, UMR 1181, B2PHI, Montigny-le-Bretonneux, France; Antimicrobial Stewardship Team, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre-Site Cochin, Paris, France.
| | - M Domenech de Cellès
- INSERM, UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology, and Infectious Diseases (B2PHI), Paris, France; Institut Pasteur, B2PHI, Paris, France; Versailles Saint-Quentin University, UMR 1181, B2PHI, Montigny-le-Bretonneux, France
| | - R Batista
- Pharmacy, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - J P Mira
- Medical Intensive Care Unit, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France; Université Paris Descartes, Sorbonne Paris cité, Paris, France
| | - C Poyart
- Université Paris Descartes, Sorbonne Paris cité, Paris, France; Department of Bacteriology, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - H Poupet
- Department of Bacteriology, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - A Casetta
- Infection Control Team, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - S Kernéis
- INSERM, UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology, and Infectious Diseases (B2PHI), Paris, France; Institut Pasteur, B2PHI, Paris, France; Versailles Saint-Quentin University, UMR 1181, B2PHI, Montigny-le-Bretonneux, France; Université Paris Descartes, Sorbonne Paris cité, Paris, France; Antimicrobial Stewardship Team, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre-Site Cochin, Paris, France
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Kjærsgaard M, Leth RA, Udupi A, Ank N. Antibiotic stewardship based on education: minor impact on knowledge, perception and attitude. Infect Dis (Lond) 2019; 51:753-763. [PMID: 31389732 DOI: 10.1080/23744235.2019.1648856] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Purpose: The purpose of this study was to implement an education-based antibiotic stewardship programme at two regional hospitals in Denmark, and thereby reduce consumption of antibiotics in general and cephalosporins and fluoroquinolones in particular. We aimed to improve physicians' knowledge, prescribing practices and perceptions and attitudes towards antibiotics, and to achieve changes in behaviour. Methods: The antibiotic stewardship programme comprised education, guidelines, audits and feedback and ward rounds by a clinical microbiologist. The ward rounds were implemented only at one hospital. The effects of the programme were evaluated using a questionnaire, audits of prescriptions (initial choice of antibiotics, indication for antibiotic treatment, re-assessment of treatment) and data on antibiotic consumption. Results: The survey revealed an improvement in junior doctors' knowledge, perception and attitude and self-reported prescribing practice. In the audit results, a larger proportion of prescribed antibiotics was in accordance with guidelines, particularly when we evaluated re-assessment of antibiotic treatment at the hospital where ward rounds had been implemented. The increase was equivalent to risk ratio (RR) 1.13 (95% confidence interval (CI): 0.95-1.35) during the intervention and RR 1.22 (95% CI 1.01-1.48) post-intervention, compared to the pre-intervention period. Penicillins as well as total antibiotic consumption increased during the study period. Conclusion: An education-based antibiotic stewardship programme can change the attitude of junior doctors and improve prescribing practices. We observed an improvement in the re-assessments of the antibiotic treatments at the hospital where a clinical microbiologist was present at ward rounds, but our persuasive methods were insufficient to reduce antibiotic consumption.
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Affiliation(s)
- Mona Kjærsgaard
- Department of Clinical Microbiology, Aarhus University Hospital , Aarhus N , Denmark
| | - Rita Andersen Leth
- Department of Clinical Microbiology, Aarhus University Hospital , Aarhus N , Denmark
| | - Aparna Udupi
- Section for Biostatistics, Department of Public Health, Aarhus University , Aarhus C , Denmark
| | - Nina Ank
- Department of Clinical Microbiology, Aarhus University Hospital , Aarhus N , Denmark
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Mattick K, Brennan N, Briscoe S, Papoutsi C, Pearson M. Optimising feedback for early career professionals: a scoping review and new framework. MEDICAL EDUCATION 2019; 53:355-368. [PMID: 30828874 DOI: 10.1111/medu.13794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/10/2018] [Accepted: 11/19/2018] [Indexed: 06/09/2023]
Abstract
CONTEXT Meta-analyses have shown that feedback can be a powerful intervention to increase learning and performance but there is significant variability in impact. New trials are adding little to the question of whether feedback interventions are effective, so the focus now is how to optimise the effect. Early career professionals (ECPs) in busy work environments are a particularly important target group. This literature review aimed to synthesise information to support the optimal design of feedback interventions for ECPs. METHODS We undertook a scoping literature review, using search terms such as 'feedback' and 'effectiveness' in MEDLINE, MEDLINE-In-Process, PsycINFO, CINAHL, Education Research Complete, Education Resources Information Center, the Cochrane Database of Systematic Reviews, the Social Sciences Citation Index and Applied Social Sciences Index and Abstracts, to identify empirical studies describing feedback interventions in busy workplaces published in English since 1990. We applied inclusion criteria to identify studies for the mapping stage and extracted key data to inform the next stage. We then selected a subset of papers for the framework development stage, which were subjected to a thematic synthesis by three authors, leading to a new feedback framework and a modified version of feedback intervention theory specifically for ECPs. RESULTS A total of 80 studies were included in the mapping stage, with roughly equal studies from hospital settings and school classrooms, and 17 papers were included in the framework development stage. The feedback framework comprised three main categories (audit, feedback and goal setting) and 22 subcategories. The review highlighted the limited empirical research focusing solely on feedback for ECPs, which was surprising given the particular nuances in feedback for ECPs identified through this study. CONCLUSIONS We offer the feedback framework to optimise the design of future feedback interventions for early career professionals and encourage future feedback research to move away from generic models and tailor work to specific target audiences.
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Affiliation(s)
- Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Simon Briscoe
- Exeter HS&DR Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Tuberculosis Treatment Outcomes and Associated Factors among TB Patients Attending Public Hospitals in Harar Town, Eastern Ethiopia: A Five-Year Retrospective Study. Tuberc Res Treat 2019; 2019:1503219. [PMID: 31057963 PMCID: PMC6463571 DOI: 10.1155/2019/1503219] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/22/2019] [Accepted: 02/21/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction Tuberculosis remains a major public health threat throughout the world particularly in developing countries. Evaluating the treatment outcome of tuberculosis and identifying the associated factors should be an integral part of tuberculosis treatment. Objectives The aim of this study was to assess the treatment outcome of tuberculosis and its associated factors among TB patients in the TB clinics of Harar public hospitals, Eastern Ethiopia, 2017. Methods A retrospective document review was conducted in two public hospitals of Harar town, located 516 km east of Addis Ababa. A systematic random sampling technique was used to select the document of TB patients who were registered in the hospitals from 1st of January, 2011, to 30th of December, 2015. The data were collected using a pretested structured data extraction format. SPSS Version 21 for window was used for data processing. Bivariate and multivariate analysis with 95% confidence interval was employed in order to infer the associations between TB treatment outcome and potential predictor variables. Results One thousand two hundred thirty-six registered TB patients' documents were reviewed. Of these, 59.8% were male, 94.2% were urban dwellers, 97% were new cases, 61.2% were presented with pulmonary TB, and 22.8% were HIV positive. Regarding the treatment outcome, 30.4% were cured, 62.1% completed their treatment, 3.9% died, 2.4% were defaulted, and the remaining 1.2% had failed treatment. The overall rate of the treatment success among the patients was 92.5%. In the present study, being female (AOR = 1.89, 95% CI: 1.14 - 3.14), having pretreatment weight of 20 – 29 kg (AOR = 11.03, 95% CI: 1.66 - 73.35), being HIV negative (AOR = 6.50, 95% CI: 3.95 - 10.71), and being new TB patient (AOR = 3.22 95% CI: 1.10 - 9.47) were factors independently associated with successful treatment outcome. On the other hand, being in the age group 54 – 64 years (AOR =10.41, 95% CI: 1.86 - 58.30) and age greater than 65 years (AOR =24.41, 95% CI: 4.19 - 142.33) was associated with unsuccessful TB treatment outcome. Conclusion In the current study, the rate of successful TB treatment outcome was acceptable. This rate should be maintained and further improved by designing appropriate monitoring strategies.
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Micallef C, Chaudhry NT, Holmes AH, Hopkins S, Benn J, Franklin BD. Secondary use of data from hospital electronic prescribing and pharmacy systems to support the quality and safety of antimicrobial use: a systematic review. J Antimicrob Chemother 2018; 72:1880-1885. [PMID: 28369528 DOI: 10.1093/jac/dkx082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 02/21/2017] [Indexed: 11/13/2022] Open
Abstract
Background Electronic prescribing (EP) and electronic hospital pharmacy (EHP) systems are increasingly common. A potential benefit is the extensive data in these systems that could be used to support antimicrobial stewardship, but there is little information on how such data are currently used to support the quality and safety of antimicrobial use. Objectives To summarize the literature on secondary use of data (SuD) from EP and EHP systems to support quality and safety of antimicrobial use, to describe any barriers to secondary use and to make recommendations for future work in this field. Methods We conducted a systematic search within four databases; we included original research studies that were (1) based on SuD from hospital EP or EHP systems and (2) reported outcomes relating to quality and/or safety of antimicrobial use and/or qualitative findings relating to SuD in this context. Results Ninety-four full-text articles were obtained; 14 met our inclusion criteria. Only two described interventions based on SuD; seven described SuD to evaluate other antimicrobial stewardship interventions and five described descriptive or exploratory studies of potential applications of SuD. Types of data used were quantitative antibiotic usage data ( n = 9 studies), dose administration data ( n = 4) and user log data from an electronic dashboard ( n = 1). Barriers included data access, data accuracy and completeness, and complexity when using data from multiple systems or hospital sites. Conclusions The literature suggests that SuD from EP and EHP systems is potentially useful to support or evaluate antimicrobial stewardship activities; greater system functionality would help to realize these benefits.
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Affiliation(s)
- Christianne Micallef
- NIHR Health Protection Research Unit, Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK.,Pharmacy Department, Addenbrooke`s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Navila T Chaudhry
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK.,NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Alison H Holmes
- NIHR Health Protection Research Unit, Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK.,Department of Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
| | - Susan Hopkins
- NIHR Health Protection Research Unit, Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK.,Public Health England, London, UK
| | - Jonathan Benn
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Bryony Dean Franklin
- NIHR Health Protection Research Unit, Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK.,Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK.,NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK.,Research Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Tavistock Square, London, UK
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Hand KS, Cumming D, Hopkins S, Ewings S, Fox A, Theminimulle S, Porter RJ, Parker N, Munns J, Sheikh A, Keyser T, Puleston R. Electronic prescribing system design priorities for antimicrobial stewardship: a cross-sectional survey of 142 UK infection specialists. J Antimicrob Chemother 2017; 72:1206-1216. [PMID: 27999065 DOI: 10.1093/jac/dkw524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 11/07/2016] [Indexed: 01/27/2023] Open
Abstract
Background The implementation of electronic prescribing and medication administration (EPMA) systems is a priority for hospitals and a potential component of antimicrobial stewardship (AMS). Objectives To identify software features within EPMA systems that could potentially facilitate AMS and to survey practising UK infection specialist healthcare professionals in order to assign priority to these software features. Methods A questionnaire was developed using nominal group technique and transmitted via email links through professional networks. The questionnaire collected demographic data, information on priority areas and anticipated impact of EPMA. Responses from different respondent groups were compared using the Mann-Whitney U -test. Results Responses were received from 164 individuals (142 analysable). Respondents were predominantly specialist infection pharmacists (48%) or medical microbiologists (37%). Of the pharmacists, 59% had experience of EPMA in their hospitals compared with 35% of microbiologists. Pharmacists assigned higher priority to indication prompt ( P < 0.001), allergy checker ( P = 0.003), treatment protocols ( P = 0.003), drug-indication mismatch alerts ( P = 0.031) and prolonged course alerts ( P = 0.041) and lower priority to a dose checker for adults ( P = 0.02) and an interaction checker ( P < 0.05) than microbiologists. A 'soft stop' functionality was rated essential or high priority by 89% of respondents. Potential EPMA software features were expected to have the greatest impact on stewardship, treatment efficacy and patient safety outcomes with lowest impact on Clostridium difficile infection, antimicrobial resistance and drug expenditure. Conclusions The survey demonstrates key differences in health professionals' opinions of potential healthcare benefits of EPMA, but a consensus of anticipated positive impact on patient safety and AMS.
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Affiliation(s)
- Kieran S Hand
- Southampton Pharmacy Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK.,Faculty of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK
| | - Debbie Cumming
- Pharmacy Department, St Mary's Hospital, Parkhurst Road, Newport, Isle of Wight PO31 7QJ, UK
| | - Susan Hopkins
- Department of Infectious Diseases & Microbiology, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Sean Ewings
- Southampton Statistical Sciences Research Institute, University of Southampton, University Road, Southampton SO17 1BJ, UK
| | - Andy Fox
- Southampton Pharmacy Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK.,Faculty of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK
| | - Sandya Theminimulle
- Microbiology Department, St Mary's Hospital, Parkhurst Road, Newport, Isle of Wight PO31 7QJ, UK
| | - Robert J Porter
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Church Lane, Heavitree, Exeter EX2 5AD, UK
| | - Natalie Parker
- Pharmacy Department, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Romsey Road, Winchester SO22 5DG, UK
| | - Joanne Munns
- Pharmacy Department, Western Sussex Hospitals NHS Foundation Trust, St Richards Hospital, Chichester PO19 6SE, UK
| | - Adel Sheikh
- Pharmacy Department, Queen Alexandra Hospital, Southwick Hill Road, Portsmouth Hospitals' NHS Trust, Portsmouth PO6 3LY, UK
| | - Taryn Keyser
- Pharmacy Department, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Aldermaston Road, Basingstoke RG24 9NA, UK
| | - Richard Puleston
- City Hospital, Institute of Public Health, Nottingham NG5 1PB, UK
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Baysari MT, Del Gigante J, Moran M, Sandaradura I, Li L, Richardson KL, Sandhu A, Lehnbom EC, Westbrook JI, Day RO. Redesign of computerized decision support to improve antimicrobial prescribing. A controlled before-and-after study. Appl Clin Inform 2017; 8:949-963. [PMID: 28905978 PMCID: PMC6220696 DOI: 10.4338/aci2017040069] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/01/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To determine the impact of the introduction of new pre-written orders for antimicrobials in a computerized provider order entry (CPOE) system on 1) accuracy of documented indications for antimicrobials in the CPOE system, 2) appropriateness of antimicrobial prescribing, and 3) compliance with the hospital's antimicrobial policy. Prescriber opinions of the new decision support were also explored to determine why the redesign was effective or ineffective in altering prescribing practices. METHODS The study comprised two parts: a controlled pre-post study and qualitative interviews. The intervention involved the redesign of pre-written orders for half the antimicrobials so that approved indications were incorporated into pre-written orders. 555 antimicrobials prescribed before (September - October, 2013) and 534 antimicrobials prescribed after (March - April, 2015) the intervention on all general wards of a hospital were audited by study pharmacists. Eleven prescribers participated in semi-structured interviews. RESULTS Redesign of computerized decision support did not result in more appropriate or compliant antimicrobial prescribing, nor did it improve accuracy of indication documentation in the CPOE system (Intervention antimicrobials: appropriateness 49% vs. 50%; compliance 44% vs. 42%; accuracy 58% vs. 38%; all p>0.05). Via our interviews with prescribers we identified five main reasons for this, primarily that indications entered into the CPOE system were not monitored or followed-up, and that the antimicrobial approval process did not align well with prescriber workflow. CONCLUSION Redesign of pre-written orders to incorporate appropriate indications did not improve antimicrobial prescribing. Workarounds are likely when compliance with hospital policy creates additional work for prescribers or when system usability is poor. Implementation of IT, in the absence of support or follow-up, is unlikely to achieve all anticipated benefits.
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Affiliation(s)
- Melissa T Baysari
- Melissa T. Baysari, Australian Institute of Health Innovation, Level 6 75 Talavera Rd, Macquarie University, NSW 2109 Australia, Phone +612 98502416,
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Toma M, Davey PG, Marwick CA, Guthrie B. A framework for ensuring a balanced accounting of the impact of antimicrobial stewardship interventions. J Antimicrob Chemother 2017; 72:3223-3231. [DOI: 10.1093/jac/dkx312] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Honda H, Ohmagari N, Tokuda Y, Mattar C, Warren DK. Antimicrobial Stewardship in Inpatient Settings in the Asia Pacific Region: A Systematic Review and Meta-analysis. Clin Infect Dis 2017; 64:S119-S126. [DOI: 10.1093/cid/cix017] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, Gould IM, Ramsay CR, Michie S. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2:CD003543. [PMID: 28178770 PMCID: PMC6464541 DOI: 10.1002/14651858.cd003543.pub4] [Citation(s) in RCA: 397] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. OBJECTIVES To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. MAIN RESULTS This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias.More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention.The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence).Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence).There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomesWe analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. AUTHORS' CONCLUSIONS We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions.
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Affiliation(s)
- Peter Davey
- University of DundeePopulation Health SciencesMackenzie BuildingKirsty Semple WayDundeeScotlandUKDD2 4BF
| | - Charis A Marwick
- University of DundeePopulation Health Sciences Division, Medical Research InstituteDundeeUK
| | - Claire L Scott
- NHS Education for ScotlandScottish Dental Clinical Effectiveness ProgrammeDundee Dental Education CentreSmall's WyndDundeeUKDD1 4HN
| | - Esmita Charani
- Imperial College LondonNIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial ResistanceDu Cane RoadLondonUKW12 OHS
| | - Kirsty McNeil
- University of DundeeSchool of Medicine147 Forth CrescentDundeeScotlandUKDD2 4JA
| | - Erwin Brown
- No affiliation31 Park CrescentFrenchayBristolUKBS16 1NZ
| | - Ian M Gould
- Aberdeen Royal InfirmaryDepartment of Medical MicrobiologyForesterhillAberdeenUKAB25 2ZN
| | - Craig R Ramsay
- University of AberdeenHealth Services Research Unit, Division of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Susan Michie
- University College LondonResearch Department of Primary Care and Population HealthUpper Floor 3, Royal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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What Drives Variation in Antibiotic Prescribing for Acute Respiratory Infections? J Gen Intern Med 2016; 31:918-24. [PMID: 27067351 PMCID: PMC4945551 DOI: 10.1007/s11606-016-3643-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 12/30/2015] [Accepted: 02/12/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Acute respiratory infections are the most common symptomatic reason for seeking care among patients in the US, and account for the majority of all antibiotic prescribing, yet a large fraction of antibiotic prescriptions are inappropriate. OBJECTIVE We sought to identify the underlying factors driving variation in antibiotic prescribing across clinicians and settings. DESIGN, PARTICIPANTS Using electronic health data for adult ambulatory visits for acute respiratory infections to a retail clinic chain and primary care practices from an integrated healthcare system, we identified a random sample of clinicians for survey. MAIN MEASURES We evaluated independent predictors of overall prescribing and imperfect antibiotic prescribing, controlling for clinician and site of care. We defined imperfect antibiotic prescribing as prescribing for non-antibiotic-appropriate diagnoses, failure to prescribe for an antibiotic-appropriate diagnosis, or prescribing a non-guideline-concordant antibiotic. KEY RESULTS Response rates were 34 % for retail clinics and 24 % for physicians' offices (N = 187). Clinicians in physicians' offices prescribed antibiotics less often than those in retail clinics (53 % versus 67 %; p < 0.01), but had a higher imperfect antibiotic prescribing rate (65 % versus 31 %; p < 0.01). Feeling rushed was associated with higher antibiotic prescribing (OR 1.34; 95 % CI 1.03, 1.75). Antibiotic prescribing was also associated with clinician disagreement that antibiotics are overused (OR 1.60, 95 % CI, 1.16, 2.20). Imperfect antibiotic prescribing was associated with receiving antibiotic prescribing feedback (OR 1.35, 95 % CI 1.04, 1.75) and disagreement that patient demand was a problem (OR 1.66, 95 % CI 1.00, 2.73). Imperfect antibiotic prescribing was less common with clinicians who perceived that they prescribed antibiotics less often than their peers (OR 0.63, 95 % CI 0.46, 0.87). CONCLUSIONS Poor-quality antibiotic prescribing was associated with feeling rushed, believing less strongly that antibiotics were overused, and believing that patient demand was not an issue, factors that can be assessed and addressed in future interventions.
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Cresswell K, Mozaffar H, Shah S, Sheikh A. Approaches to promoting the appropriate use of antibiotics through hospital electronic prescribing systems: a scoping review. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2016; 25:5-17. [DOI: 10.1111/ijpp.12274] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 04/20/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Kathrin Cresswell
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
| | - Hajar Mozaffar
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
| | | | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
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Gilchrist M, Wade P, Ashiru-Oredope D, Howard P, Sneddon J, Whitney L, Wickens H. Antimicrobial Stewardship from Policy to Practice: Experiences from UK Antimicrobial Pharmacists. Infect Dis Ther 2015; 4:51-64. [PMID: 26362295 PMCID: PMC4569645 DOI: 10.1007/s40121-015-0080-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Indexed: 11/28/2022] Open
Abstract
Antimicrobial stewardship in the UK has evolved dramatically in the last 15 years. Factors driving this include initial central funding for specialist pharmacists and mandatory reductions in healthcare-associated infections (particularly Clostridium difficile infection). More recently, the introduction of national stewardship guidelines, and an increased focus on stewardship as part of the UK five-year antimicrobial resistance strategy, have accelerated and embedded developments. Antimicrobial pharmacists have been instrumental in effecting changes at an organizational and national level. This article describes the evolution of the antimicrobial pharmacist role, its impact, the progress toward the actions listed in the five-year resistance strategy, and novel emerging areas in stewardship in the UK.
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Affiliation(s)
- Mark Gilchrist
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK.
| | - Paul Wade
- Guy's and St. Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | | | - Philip Howard
- Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, LS1 3EX, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, 50 West Nile Street, Glasgow, G1 2NP, UK
| | - Laura Whitney
- St George's University Hospital NHS Foundation Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Hayley Wickens
- University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
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Lehmann CU, Haux R. From bench to bed: bridging from informatics theory to practice. An exploratory analysis. Methods Inf Med 2014; 53:511-5. [PMID: 25377761 DOI: 10.3414/me14-01-0098] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND In 2009, the journal Applied Clinical Informatics (ACI) commenced publication. Focused on applications in clinical informatics, ACI was intended to be a companion journal to METHODS of Information in Medicine (MIM). Both journals are official journals of IMIA, the International Medical Informatics Association. OBJECTIVES To explore, after five years, which congruencies and interdependencies exist in publications of these journals and to determine if gaps exist. To achieve this goal, major topics discussed in ACI and in MIM had to be analysed. Finally, we wanted to explore, whether the intention of publishing these companion journals to provide an information bridge from informatics theory to informatics practice and from practice to theory could be supported by this model. In this manuscript we will report on congruencies and interdependencies from practise to theory and on major topis in ACI. Further results will be reported in a second paper. METHODS Retrospective, prolective observational study on recent publications of ACI and MIM. All publications of the years 2012 and 2013 from these journals were indexed and analysed. RESULTS Hundred and ninety-six publications have been analysed (87 ACI, 109 MIM). In ACI publications addressed care coordination, shared decision support, and provider communication in its importance for complex patient care and safety and quality. Other major themes included improving clinical documentation quality and efficiency, effectiveness of clinical decision support and alerts, implementation of health information technology systems including discussion of failures and succeses. An emerging topic in the years analyzed was a focus on health information technology to predict and prevent hospital admissions and managing population health including the application of mobile health technology. Congruencies between journals could be found in themes, but with different focus in its contents. Interdependencies from practise to theory found in these publications, were only limited. CONCLUSIONS Bridging from informatics theory to practise and vice versa remains a major component of successful research and practise as well as a major challenge.
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Affiliation(s)
- C U Lehmann
- Prof. Dr. Christoph U. Lehmann, Pediatrics and Biomedical Informatics, Vanderbilt University, 2200 Children's Way, 11111 Doctors' Office Tower, Nashville, TN 37232-9544, USA, E-mail:
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Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013:CD003543. [PMID: 23633313 DOI: 10.1002/14651858.cd003543.pub3] [Citation(s) in RCA: 351] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The first publication of this review in Issue 3, 2005 included studies up to November 2003. This update adds studies to December 2006 and focuses on application of a new method for meta-analysis of interrupted time series studies and application of new Cochrane Effective Practice and Organisation of Care (EPOC) Risk of Bias criteria to all studies in the review, including those studies in the previously published version. The aim of the review is to evaluate the impact of interventions from the perspective of antibiotic stewardship. The two objectives of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second support professionals and patients to reduce unnecessary use and minimize collateral damage. OBJECTIVES To estimate the effectiveness of professional interventions that, alone or in combination, are effective in antibiotic stewardship for hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial-resistant pathogens or Clostridium difficile infection and their impact on clinical outcome. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE from 1980 to December 2006 and the EPOC specialized register in July 2007 and February 2009 and bibliographies of retrieved articles. The main comparison is between interventions that had a restrictive element and those that were purely persuasive. Restrictive interventions were implemented through restriction of the freedom of prescribers to select some antibiotics. Persuasive interventions used one or more of the following methods for changing professional behaviour: dissemination of educational resources, reminders, audit and feedback, or educational outreach. Restrictive interventions could contain persuasive elements. SELECTION CRITERIA We included randomized clinical trials (RCTs), controlled clinical trials (CCT), controlled before-after (CBA) and interrupted time series studies (ITS). Interventions included any professional or structural interventions as defined by EPOC. The intervention had to include a component that aimed to improve antibiotic prescribing to hospital inpatients, either by increasing effective treatment or by reducing unnecessary treatment. The results had to include interpretable data about the effect of the intervention on antibiotic prescribing or microbial outcomes or relevant clinical outcomes. DATA COLLECTION AND ANALYSIS Two authors extracted data and assessed quality. We performed meta-regression of ITS studies to compare the results of persuasive and restrictive interventions. Persuasive interventions advised physicians about how to prescribe or gave them feedback about how they prescribed. Restrictive interventions put a limit on how they prescribed; for example, physicians had to have approval from an infection specialist in order to prescribe an antibiotic. We standardized the results of some ITS studies so that they are on the same scale (percent change in outcome), thereby facilitating comparisons of different interventions. To do this, we used the change in level and change in slope to estimate the effect size with increasing time after the intervention (one month, six months, one year, etc) as the percent change in level at each time point. We did not extrapolate beyond the end of data collection after the intervention. The meta-regression was performed using standard weighted linear regression with the standard errors of the coefficients adjusted where necessary. MAIN RESULTS For this update we included 89 studies that reported 95 interventions. Of the 89 studies, 56 were ITSs (of which 4 were controlled ITSs), 25 were RCT (of which 5 were cluster-RCTs), 5 were CBAs and 3 were CCTs (of which 1 was a cluster-CCT).Most (80/95, 84%) of the interventions targeted the antibiotic prescribed (choice of antibiotic, timing of first dose and route of administration). The remaining 15 interventions aimed to change exposure of patients to antibiotics by targeting the decision to treat or the duration of treatment. Reliable data about impact on antibiotic prescribing data were available for 76 interventions (44 persuasive, 24 restrictive and 8 structural). For the persuasive interventions, the median change in antibiotic prescribing was 42.3% for the ITSs, 31.6% for the controlled ITSs, 17.7% for the CBAs, 3.5% for the cluster-RCTs and 24.7% for the RCTs. The restrictive interventions had a median effect size of 34.7% for the ITSs, 17.1% for the CBAs and 40.5% for the RCTs. The structural interventions had a median effect of 13.3% for the RCTs and 23.6% for the cluster-RCTs. Data about impact on microbial outcomes were available for 21 interventions but only 6 of these also had reliable data about impact on antibiotic prescribing.Meta-analysis of 52 ITS studies was used to compare restrictive versus purely persuasive interventions. Restrictive interventions had significantly greater impact on prescribing outcomes at one month (32%, 95% confidence interval (CI) 2% to 61%, P = 0.03) and on microbial outcomes at 6 months (53%, 95% CI 31% to 75%, P = 0.001) but there were no significant differences at 12 or 24 months. Interventions intended to decrease excessive prescribing were associated with reduction in Clostridium difficile infections and colonization or infection with aminoglycoside- or cephalosporin-resistant gram-negative bacteria, methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis. Meta-analysis of clinical outcomes showed that four interventions intended to increase effective prescribing for pneumonia were associated with significant reduction in mortality (risk ratio 0.89, 95% CI 0.82 to 0.97), whereas nine interventions intended to decrease excessive prescribing were not associated with significant increase in mortality (risk ratio 0.92, 95% CI 0.81 to 1.06). AUTHORS' CONCLUSIONS The results show that interventions to reduce excessive antibiotic prescribing to hospital inpatients can reduce antimicrobial resistance or hospital-acquired infections, and interventions to increase effective prescribing can improve clinical outcome. This update provides more evidence about unintended clinical consequences of interventions and about the effect of interventions to reduce exposure of patients to antibiotics. The meta-analysis supports the use of restrictive interventions when the need is urgent, but suggests that persuasive and restrictive interventions are equally effective after six months.
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Affiliation(s)
- Peter Davey
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK.
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