Antibacterial agents and the fight against antibiotic resistance: A real-world evidence analysis of consumption and spending by an Italian healthcare company

INTRODUCTION

The escalating bacterial resistance stands as an increasingly pertinent concern, particularly in the post-pandemic era where the use of antibiotics appears to be relentlessly surging, giving rise to profound apprehensions. The substantial utilization of last-generation penicillins and cephalosporins is anticipated to imminently result in the emergence of superbugs for which therapeutic solutions will be scarce.

METHODS

An analysis of antibiotic consumption in the hospital setting has been conducted in an Italian healthcare organization. Querying the internal management system facilitated the calculation of indicators and assessment of prescription trends.

RESULTS

A comparison has been made between the first half of 2023 and the first half of 2022, to highlight the exponential growth in the consumption of beta-lactam antibiotics, with consumption doubling compared to the previous year's semester. Overall, considering the prescription averages, there is a prescribing growth of +29% concerning hospitalization and +28% concerning hospital discharge. However, it should be noted that the consumption of certain antibiotics such as sulphonamides and trimethoprim (-103.00%), tetracyclines (-54.00%), macrolides, lincosamides and streptogramins (-50.00%) and colistin (-13.00%) decreased.

CONCLUSION

This real-world evidence analysis aimed to support the justified and comprehensible global concerns regarding bacterial resistance. The extensive consumption of antibiotics will inevitably lead to the development of increasingly drug-resistant bacteria for which no antibiotic may be efficacious. National programs addressing antibiotic resistance and the awareness of all healthcare personnel must be accorded the utmost priority to enhance consumption data and, consequently, safeguard future human survival.

How appropriate is treating patients diagnosed with advanced esophageal cancer with anticancer drugs? A multicenter retrospective cohort Spanish study

AIM

To assess the appropriateness of systemic oncological treatments (SOT) provided to patients diagnosed with advanced esophageal cancer (EC) across a group of participating hospitals.

METHODS

Multicenter, retrospective cohort study in five Spanish hospitals including newly confirmed advanced EC cases between July 1, 2014, and June 30, 2016, with a 5-year follow-up.

RESULTS

We identified 157 patients fulfilling the inclusion criteria (median age: 65 years, 85.9% males). Most patients, 125 (79.6%) were treated at least with one active treatment, and 33% received two or more lines of SOT. The 1-, 2- and 5-year overall survival rates were 30.3% [95%CI: 23.8, 38.7], 14.0% [95%CI: 9.3, 21.0], and 7.1% [95% CI: 3.8, 13.1] respectively, and the median survival time 8 months (95% CI: 6, 19) for stages IIIb IIIc and 7 months (95% CI: 5, 9) for stage IV. Clinical stage, receiving more than one line of SOT, and treatment with radiotherapy accelerated the time to death (0.4, 0.9-, and 0.8-times shorter survival respectively, p < 0.05). Better performance status (ECOG < 2) extended survival time by 2.2 times (p = 0.04). Age < 65 years (OR 9.4, 95% CI 3.2, 31.4, p < 0.001), and being treated in one particular hospital (OR 0.2, 95% CI 0.0, 0.8, p < 0.01) were associated with the administration of two or more lines of SOT. Altogether, 18.9% and 9.0% of patients received chemotherapy in the last four and two weeks of life, respectively. Moreover, 2.5% of patients were prescribed a new line of chemotherapy during the last month of life. The proportion of all patients who did not have access to palliative care reached 29.3%, and among those who had access to it, 34.2% initiated it in the last month of life.

CONCLUSION

A high proportion of advanced EC patients receive many treatments not based on sound evidence and they do not benefit enough from palliative care services. The most accepted appropriateness indicators point out that some of the analyzed patients could have been overtreated. This study provides important insights into the quality of care provided to advanced EC, and furthermore, for giving valuable insight and opportunities for improvement.

Identification of an ultra-rare Alu insertion in the CFTR gene: Pitfalls and challenges in genetic test interpretation

Cystic fibrosis (CF) is a life-limiting genetic disorder characterized by defective chloride ion transport due to mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Early detection through newborn screening programs significantly improves outcomes for individuals with CF by enabling timely intervention. Here, we report the identification of an Alu element insertion within the exon 15 of CFTR gene, initially overlooked in standard next-generation sequencing analyses. However, using traditional molecular techniques, based on polymerase chain reaction and Sanger sequencing, allowed the identification of the Alu element and the reporting of a correct diagnosis. Our analysis, based on bioinformatics tools and molecular techniques, revealed that the Alu element insertion severely affects the gene expression, splicing patterns, and structure of CFTR protein. In conclusion, this study emphasizes the importance of how the integration of human expertise and modern technologies represents a pivotal step forward in genomic medicine, ensuring the delivery of precision healthcare to individuals affected by genetic diseases.

Appropriateness of implantable cardioverter-defibrillator device implants in the United States

BACKGROUND

The appropriate use criteria (AUCs) are a diverse group of indications aimed to better evaluate the benefits of implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy.

OBJECTIVE

The purpose of this study was to quantify the proportion of ICD and cardiac resynchronization therapy with defibrillator (CRT-D) implants as appropriate, may be appropriate (MA), or rarely appropriate (RA) on the basis of the AUC guidelines.

METHODS

This is a multicenter retrospective study of patients within the National Cardiovascular Data Registry undergoing ICD implantation between April 2018 and March 2019 at >1500 US hospitals. The appropriateness of ICD implants was adjudicated using the AUC.

RESULTS

Of 309,318 ICDs, 241,438 were primary prevention implants (78.1%) and 67,880 secondary prevention implants (21.9%); 243,532 (79%) were mappable to the AUC. For primary prevention, 185,431 ICDs (96.4%) were appropriate, 5660 (2.9%) MA, and 1205 (0.6%) RA. For secondary prevention, 47,498 ICDs (92.7%) were appropriate, 2581 (5%) MA, and 1157 (2.3%) RA. A significant number of RA devices were implanted in patients with New York Heart Association class IV heart failure who were ineligible for advanced therapies (53.9%) and those with myocardial infarction within 40 days (18.1%). The appropriateness of the pacing lead was more variable, with 48,470 dual-chamber ICD implants (62%) being classified as appropriate, 29,209 (37.4%) MA, and 448 (0.6%) RA. Among CRT-D implants, 63,848 (82.2%) were appropriate, 9900 (12.7%) MA, and 3940 (5.1%) RA for left ventricular pacing. A total of 99,754 implants were deemed appropriate but excluded from Centers for Medicare & Medicaid Services National Coverage Determination. More than 92% of hospitals had an RA implant rate of <4%.

CONCLUSION

In this large national registry, 95% of mappable ICD and CRT-D implants were considered appropriate, with <2% of RA implants. Nearly 100,000 appropriate implants are excluded by Centers for Medicare & Medicaid Services National Coverage Determination.

Developing realistic benchmarks for glaucoma care delivery

CLINICAL RELEVANCE

Realistic benchmarks can serve as comparators for optometrists wishing to engage in clinical practice audits of their glaucoma care.

BACKGROUND

The iCareTrack study established the appropriateness of glaucoma care delivery through clinical record audits of Australian optometry practices. Benchmarks required for monitoring and improving glaucoma care delivery do not exist. This study developed realistic benchmarks for glaucoma care and then benchmarked the performance of practices from the iCareTrack study to establish aspects of care that warrant attention from quality improvement initiatives.

METHODS

Benchmarks were developed from the pre-existing iCareTrack dataset using the Achievable Benchmarks of Care (ABC) method. The iCareTrack study had audited the appropriateness of glaucoma care delivery against 37 clinical indicators for 420 randomly sampled glaucoma patient records from 42 Australian optometry practices. The four-step ABC method calculates benchmarks based on the top 10% of best-performing practices adjusted for low patient encounter numbers. iCareTrack results were compared to the benchmarks to explore the distribution of practices that were at, above or below benchmark.

RESULTS

Benchmarks were developed for 34 of 37 iCareTrack indicators. For 26 (of 34) indicators, the benchmarks were at or above 90% appropriateness. The benchmarks for 14 (of 34) iCareTrack indicators were met by more than 80% of eligible practices, indicating excellent performance. Some aspects of glaucoma care such as peripheral anterior angle assessment, applanation tonometry, and visual field assessment appeared to be delivered sub-optimally by optometrists when compared to the benchmarks.

CONCLUSION

This study established benchmarks for glaucoma care delivery in optometry practices that reflect realistic and top achievable performance. The large number of indicators with benchmarks above 90% confirmed that glaucoma care can and should be delivered by optometrists at very high levels of appropriateness. Benchmarking identified pockets of sub-optimal performance that can now be targeted by quality improvement initiatives.

Recovery of suspended reimbursements of high-cost drugs subjected to monitoring registries and negotiated agreements (MEAs): a tool for governance and clinical appropriateness in the Italian reality

The Monitoring Registries and negotiated agreements (MEAs) established by the Italian Medicines Agency (AIFA) exemplify a pinnacle of excellence in Italian healthcare governance, playing a pivotal role in achieving economic sustainability and ensuring judicious allocation of financial resources. Within a local territorial health company catering to a populace of around 1 million individuals in Italy, an assessment of the meticulous implementation of all negotiation procedures was carried out by scrutinizing the monitoring records. This examination served to pinpoint and address potential issues in the platform management executed by healthcare professionals, including physicians and pharmacists. Such issues had the potential to result in economic setbacks owing to the non-reimbursement from pharmaceutical companies. Through diligent verification undertaken by the pharmacists, a financial recovery amounting to approximately €579,443.4 for the fiscal year 2022 was achieved. The essence of this analysis is to underscore how collaborative, multidisciplinary efforts between physicians and pharmacists yield tangible economic advantages. This collaborative approach ensures a streamlined healthcare system characterized by efficiency, devoid of unnecessary expenditures, and marked by the highest standards of care appropriateness, ultimately serving the best interests of the citizens.

Clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: pediatric congenital heart disease conditions

BACKGROUND

The use of medical 3D printing (focusing on anatomical modeling) has continued to grow since the Radiological Society of North America's (RSNA) 3D Printing Special Interest Group (3DPSIG) released its initial guideline and appropriateness rating document in 2018. The 3DPSIG formed a focused writing group to provide updated appropriateness ratings for 3D printing anatomical models across a variety of congenital heart disease. Evidence-based- (where available) and expert-consensus-driven appropriateness ratings are provided for twenty-eight congenital heart lesion categories.

METHODS

A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with pediatric congenital heart disease indications. Each study was vetted by the authors and strength of evidence was assessed according to published appropriateness ratings.

RESULTS

Evidence-based recommendations for when 3D printing is appropriate are provided for pediatric congenital heart lesions. Recommendations are provided in accordance with strength of evidence of publications corresponding to each cardiac clinical scenario combined with expert opinion from members of the 3DPSIG.

CONCLUSIONS

This consensus appropriateness ratings document, created by the members of the RSNA 3DPSIG, provides a reference for clinical standards of 3D printing for pediatric congenital heart disease clinical scenarios.

The Italian experience with the use of monitoring registers attached to negotiated agreements (MEAs) of the Italian Medicines Agency is a tool for governance and clinical appropriateness

The use of monitoring registers with annexed negotiation agreements (MEAs) of the Italian Medicines Agency (AIFA) are the pillar of Italian healthcare governance to guarantee the correct allocation of economic healthcare resources. In Italy, an analysis was conducted in the context of a local health authority where all negotiation activities were implemented to verify the amount of reimbursements that can be recovered through the use of all available procedures on the monitoring registers. The purpose of this analysis was to highlight any criticalities which, if not properly addressed by doctors and pharmacists, can lead to considerable financial loss. Correct verification by the hospital pharmacy resulted in an economic recovery of approximately EUR 579,443.40 for the year 2022 and EUR 682,225.30 in the first 9 months of 2023. This analysis is intended to highlight how effective collaboration between doctors and pharmacists can lead to clear economic advantages with an efficient health system to the total benefit of citizens.

Clinical situations for which 3D Printing is considered an appropriate representation or extension of data contained in a medical imaging examination: vascular conditions

BACKGROUND

Medical three-dimensional (3D) printing has demonstrated utility and value in anatomic models for vascular conditions. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (3DPSIG) provides appropriateness recommendations for vascular 3D printing indications.

METHODS

A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with vascular indications. Each study was vetted by the authors and strength of evidence was assessed according to published appropriateness ratings.

RESULTS

Evidence-based recommendations for when 3D printing is appropriate are provided for the following areas: aneurysm, dissection, extremity vascular disease, other arterial diseases, acute venous thromboembolic disease, venous disorders, lymphedema, congenital vascular malformations, vascular trauma, vascular tumors, visceral vasculature for surgical planning, dialysis access, vascular research/development and modeling, and other vasculopathy. Recommendations are provided in accordance with strength of evidence of publications corresponding to each vascular condition combined with expert opinion from members of the 3DPSIG.

CONCLUSION

This consensus appropriateness ratings document, created by the members of the 3DPSIG, provides an updated reference for clinical standards of 3D printing for the care of patients with vascular conditions.

Clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: neurosurgical and otolaryngologic conditions

BACKGROUND

Medical three dimensional (3D) printing is performed for neurosurgical and otolaryngologic conditions, but without evidence-based guidance on clinical appropriateness. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (SIG) provides appropriateness recommendations for neurologic 3D printing conditions.

METHODS

A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with neurologic and otolaryngologic conditions. Each study was vetted by the authors and strength of evidence was assessed according to published guidelines.

RESULTS

Evidence-based recommendations for when 3D printing is appropriate are provided for diseases of the calvaria and skull base, brain tumors and cerebrovascular disease. Recommendations are provided in accordance with strength of evidence of publications corresponding to each neurologic condition combined with expert opinion from members of the 3D printing SIG.

CONCLUSIONS

This consensus guidance document, created by the members of the 3D printing SIG, provides a reference for clinical standards of 3D printing for neurologic conditions.

Enhancing the appropriateness of eyecare delivery: the iCaretrack approach

Optometrists play an integral role in primary eyecare services, including prevention, diagnosis, and management of acute and chronic eye conditions. Therefore, it remains essential that the care they provide be timely and appropriate to ensure the best patient outcomes and optimal utilisation of resources. However, optometrists continuously face many challenges that can affect their ability to provide appropriate care (i.e., the care in line with evidence-based clinical practice guidelines). To address any resulting evidence-to-practice gaps, programs are needed that support and enable optometrists to adopt and utilise the best evidence in clinical practice. Implementation science is a field of research that can be applied to improving the adoption and maintenance of evidence-based practices in routine care, through systematic development and application of strategies or interventions to address barriers to evidence-based practice. This paper demonstrates an approach using implementation science to enhance optometric eyecare delivery. A brief overview of the methods used to identify existing gaps in appropriate eyecare delivery is presented. An outline of the process used to understand the behavioural barriers responsible for such gaps follows, involving theoretical models and frameworks. The resulting development of an online program for optometrists to enhance their capability, motivation, and opportunity to provide evidence-based eyecare is described, using the Behaviour Change Model and co-design methods. The importance of and methods used in evaluating such programs are also discussed. Finally, reflections on the experience and key learnings from the project are shared. While the paper focuses on experiences in improving glaucoma and diabetic eyecare in the Australian optometry context, this approach can be adapted to other conditions and contexts.

Looking for appropriateness in follow-up CT of oncologic patients: Results from a cross-sectional study

PURPOSE

The objective of this study was to assess the inappropriateness rate of oncological follow-up CT examinations.

METHODS

Out of 7.000 oncology patients referred for follow-up CT examinations between March and October 2022, a random sample of 10 % was included. Radiology residents assessed the appropriateness using the Italian Society of Medical Oncology (AIOM) guidelines, supervised by senior radiologists. Association between inappropriateness and clinical variables was investigated and variables influencing inappropriateness were analyzed through a binary logistic regression.

RESULTS

Three-hundred-eighty-eight examinations (56.1 %) were consistent with AIOM guidelines. An additional 100 (14.5  %) examinations did not follow the recommended schedule but were nevertheless considered appropriate because of suspected recurrence/progression (10.7 %) or adverse event requiring imaging assessment (3.8 %). Two-hundred-four (29.4 %) examinations were rated as inappropriate. Inappropriateness causes were as follows: CT not included in the relevant guideline (n = 47); CT extended to additional anatomical regions (n = 59); CT requested at a shorter time-interval (n = 98). No statistically significant difference was found in age, sex, scan region, and primary cancer between appropriate and inappropriate examinations. The only variable significantly associated with inappropriateness was being referred by a specific hospital unit named "unit 2" in the study (p = 0.009), which was demonstrated to be the only appropriateness independent predictor (OR 1.952).

CONCLUSION

This study shows that majority of oncological patients referred for follow-up CT follows standard guidelines. However, a non-negligible proportion was rated as inappropriate, mainly due to the shorter time-interval. No clinical variable was associated with inappropriateness, except for referral by a specific hospital unit.

Prescriptive behavior of non-vitamin K oral anticoagulants in patients affected by atrial fibrillation in general practice

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and in recent years the pharmacological approach has been strongly implemented; in Italy, the prescription of the non-vitamin K oral anticoagulants (NOAC) was also extended to General Practitioners (GPs) since 2020. The aim of the present study was to investigate the GPs prescribing behaviour of NOACs. An observational study was performed by using the computerized medical record of 14 GPs in Sicily: patients affected by AF were selected and stratified according to the prescribed antithrombotic drugs. Patients were considered inadequately managed if antithrombotic treatment was not adherent to recent ESC guidelines. A total of 467 (2.7 %) patients were affected by AF, 276 (59.1 %) were treated with an oral anticoagulant (OAC) regardless the high stroke risk (OR 1.64; 95 %CI 0.74-3.62; p = 0.226). The NOAC users were 236 patients as follow: Rivaroxaban 33.5 %, Apixaban 33,1 %, Dabigatran 17,4 %, Edoxaban 16.1 %. In 7 patients an inappropriate NOAC treatment was observed. Among Vitamin-K antagonist users, 25.0 % were considered inappropriate. Patients not treated with OAC were 191, of them 81.7 % were at high stroke risk and did not receive any OAC despite the indication to treat. In addition, the probability to be not properly managed significantly increased in older and in patients with atherosclerosis. Conversely, patients with at least one reported cardiology counselling significantly reduced the likelihood to be not properly managed (OR 0.38, 95 %CI 0.25-0.58; p 0.01). Our results suggest the need to optimize the management of real-life AF patients by improving prescribing adherence to ESC guidelines.

Applicability and limitations of quality indicator-based assessment of appropriateness in antimicrobial use: a comparison with expert opinion

BACKGROUND

The effective implementation of antimicrobial stewardship requires an a-priori assessment of the appropriateness of antimicrobial prescriptions.

AIM

To evaluate the effectiveness of quality indicators (QIs) in determining the appropriateness of antimicrobial prescriptions compared to that of expert opinions.

METHODS

The study assessed antimicrobial use in 20 hospitals in Korea, with infectious disease specialists rating the appropriateness based on QIs and expert opinions. The selected QIs were (1) taking two blood cultures, (2) taking cultures from suspected sites of infection, (3) prescribing empirical antimicrobials according to guidelines, and (4) changing from empirical to pathogen-directed therapy for hospitalized patients and (2, 3, and 4) for ambulatory patients. Applicability, compliance with QIs, and agreement between QIs and expert opinions were investigated.

FINDINGS

Overall, 7999 therapeutic uses of antimicrobials were investigated at the study hospitals. The experts rated 20.5% (1636/7999) as inappropriate use. For hospitalized patients, antimicrobial use was assessed based on all four QIs in 28.8% (1798/6234) of the cases. For ambulatory care patients, only 7.5% (102/1351) of the antimicrobial use cases were assessed using all three QIs. The agreement between expert opinions and all four QIs for hospitalized patients was minimal (κ = 0.332), whereas that between expert opinions and all three QIs for ambulatory patients was weak (κ = 0.598).

CONCLUSION

QIs have limitations in determining the appropriateness of antimicrobial use, and the degree of agreement with expert opinions was low. Therefore, these QI limitations should be considered when determining the appropriateness of antimicrobial use.

CT and MRI imaging in Sweden: retrospective appropriateness analysis of large referral samples

OBJECTIVES

The numbers of computed tomography (CT) and magnetic resonance imaging (MRI) examinations per capita continue to increase in Sweden and in other parts of Europe. The appropriateness of CT and MRI examinations was audited using established European appropriateness criteria. Alternative modalities were also explored. The results were compared with those of a previous study performed in Sweden.

METHODS

A semi-automatic retrospective evaluation of referrals from examinations performed in four healthcare regions using the European appropriateness criteria in ESR iGuide was undertaken. The clinical indications from a total of 13,075 referrals were assessed against these criteria. The ESR iGuide was used to identify alternative modalities resulting in a higher degree of appropriateness. A qualitative comparison with re-evaluated results from the previous study was made.

RESULTS

The appropriateness was higher for MRI examinations than for CT examinations with procedures classed as usually appropriate for 76% and 63% of the examinations, respectively. The degree of appropriateness for CT was higher for referrals from hospitals compared to those from primary care centres. The opposite was found for MRI examinations. The alternative modalities that would result in higher appropriateness included all main imaging modalities. The result for CT did not show improvement compared with the former study.

CONCLUSIONS

A high proportion of both CT and MRI examinations were inappropriate. The study indicates that 37% of CT examinations and 24% of MRI examinations were inappropriate and that the appropriateness for CT has not improved in the last 15 years.

CRITICAL RELEVANCE STATEMENT

A high proportion of CT and MRI examinations in this retrospective study using evidence-based referral guidelines were inappropriate.

KEY POINTS

∙ A high proportion of CT and MRI examinations were inappropriate. ∙ The CT referrals from general practitioners were less appropriate that those from hospital specialists. ∙ The MRI referrals from hospital specialists were less appropriate that those from general practitioners. ∙ Adherence to radiological appropriateness guidelines may improve the appropriateness of conducted examinations.

Ten years of implementation outcomes research: a scoping review

BACKGROUND

Proctor and colleagues' 2011 paper proposed a taxonomy of eight implementation outcomes and challenged the field to address a research agenda focused on conceptualization, measurement, and theory building. Ten years later, this paper maps the field's progress in implementation outcomes research. This scoping review describes how each implementation outcome has been studied, research designs and methods used, and the contexts and settings represented in the current literature. We also describe the role of implementation outcomes in relation to implementation strategies and other outcomes.

METHODS

Arksey and O'Malley's framework for conducting scoping reviews guided our methods. Using forward citation tracing, we identified all literature citing the 2011 paper. We conducted our search in the Web of Science (WOS) database and added citation alerts sent to the first author from the publisher for a 6-month period coinciding with the WOS citation search. This produced 1346 titles and abstracts. Initial abstract screening yielded 480 manuscripts, and full-text review yielded 400 manuscripts that met inclusion criteria (empirical assessment of at least one implementation outcome).

RESULTS

Slightly more than half (52.1%) of included manuscripts examined acceptability. Fidelity (39.3%), feasibility (38.6%), adoption (26.5%), and appropriateness (21.8%) were also commonly examined. Penetration (16.0%), sustainability (15.8%), and cost (7.8%) were less frequently examined. Thirty-two manuscripts examined implementation outcomes not included in the original taxonomy. Most studies took place in healthcare (45.8%) or behavioral health (22.5%) organizations. Two-thirds used observational designs. We found little evidence of progress in testing the relationships between implementation strategies and implementation outcomes, leaving us ill-prepared to know how to achieve implementation success. Moreover, few studies tested the impact of implementation outcomes on other important outcome types, such as service systems and improved individual or population health.

CONCLUSIONS

Our review presents a comprehensive snapshot of the research questions being addressed by existing implementation outcomes literature and reveals the need for rigorous, analytic research and tests of strategies for attaining implementation outcomes in the next 10 years of outcomes research.

Individual-level associations between implementation leadership, climate, and anticipated outcomes: a time-lagged mediation analysis

BACKGROUND

Leaders can improve implementation outcomes by developing an organizational climate conducive to the implementation of evidence-based practices (EBP). This study tested the lagged associations between individual-level perceptions of implementation leadership, implementation climate, and three anticipated implementation outcomes, that is EBP acceptability, appropriateness, and feasibility.

METHODS

Screening tools and treatment methods for posttraumatic stress disorder were implemented in 43 Norwegian mental health services. A sample of 494 child and adult mental health care professionals (M = 43 years, 78% female) completed surveys addressing perceptions of first-level leaders' (n = 47) implementation leadership and their clinics' implementation climate. Single-level structural equation models estimating both direct, indirect, and total effects were used to investigate whether perceived implementation climate mediated the association between perceived implementation leadership and perceived acceptability, appropriateness, and feasibility of screening tools and treatment methods.

RESULTS

Regarding the treatment methods, implementation leadership was associated with therapists' perceptions of acceptability, appropriateness, and feasibility. Implementation climate also mediated between implementation leadership and the outcomes. Regarding the screening tools, implementation leadership was not associated with the outcomes. However, implementation climate mediated between implementation leadership and therapists' perceptions of acceptability and feasibility, but not appropriateness. Analyses with the implementation climate subscales showed stronger associations for therapists' perceptions of the treatment methods than of screening tools.

CONCLUSIONS

Leaders may promote positive implementation outcomes, both directly and through implementation climate. With regard to the effect sizes and explained variance, results indicated that both implementation leadership and implementation climate were more strongly associated with the therapists' perceptions of the treatment methods, implemented by one group of therapists, than the screening tools, implemented by all therapists. This may imply that implementation leadership and climate may have stronger effects for smaller implementation teams within a larger system than for system-wide implementations or when the clinical interventions being implemented are more complex rather than simple ones.

TRIAL REGISTRATION

ClinicalTrials NCT03719651, 25 October 2018.

Appropriateness and diagnostic yield of open access gastroscopy in two tertiary centers in South-western Nigeria

Background

There is need for the appropriate use of gastroscopy.

Objective

To determine the appropriateness of upper gastrointestinal endoscopy, and its association with significant endoscopy findings in our environment.

Methods

This was a prospective study of subjects who underwent gastroscopy at two centers in south-western Nigeria between August 2020 and August 2021. Indications were classified as either appropriate or inappropriate according to the ASGE guidelines, gastroscopic findings as either significant or not significant, patients as either elderly (≥ 60 years) or not, inpatients or outpatients, and referrals as either gastroenterologist referral, or not.

Results

There were 227 subjects, 131 (57.7%) females, mean age 45 ± 13.7 years. Fifteen percent were elderly, 65.6% were gastroenterologist referrals, 14.1% were inpatients, while 45.8% had co-morbidities. Endoscopy was appropriately indicated in 81.9%, and significant endoscopy findings were detected in 95.6%. Appropriateness was not associated with significant endoscopy findings. The sensitivity, specificity and AUROC of the ASGE guidelines were 10%, 82%, and 0.46 respectively.

Conclusion

According to our study, most procedures are appropriately indicated. However, appropriateness did not determine endoscopy yield. Larger studies are needed to determine the utility of the ASGE guidelines in our environment.

Measuring appropriateness of diagnostic imaging: a scoping review

In radiology, the justification of diagnostic imaging is a key performance indicator. To date, specific recommendations on the measurement of appropriateness in diagnostic imaging are missing. To map the study literature concerning the definition, measures, methods and data used for analyses of appropriateness in research of diagnostic imaging. We conducted a scoping review in Medline, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials. Two independent reviewers undertook screening and data extraction. After screening 6021 records, we included 50 studies. National guidelines (n = 22/50) or American College of Radiology Appropriateness Criteria (n = 23/50) were used to define and rate appropriateness. 22/50 studies did not provide methodological details about the appropriateness assessment. The included studies varied concerning modality, amount of reviewed examinations (88-13,941) and body regions. Computed tomography (27 studies, 27,168 examinations) was the most frequently analyzed modality, followed by magnetic resonance imaging (17 studies, 6559 examinations) and radiography (10 studies, 7095 examinations). Heterogeneous appropriateness rates throughout single studies (0-100%), modalities, and body regions (17-95%) were found. Research on pediatric and outpatient imaging was sparse. Multicentric, methodologically robust and indication-oriented studies would strengthen appropriateness research in diagnostic imaging and help to develop reliable key performance indicators.

Appropriateness of lumbar spine radiography and factors influencing imaging ordering patterns: paving the path towards value-driven healthcare

BACKGROUND

The demand for diagnostic imaging continues to rise. Against the backdrop of rising healthcare costs and finite resources, this has prompted a paradigm shift towards value-driven patient care. Inappropriate imaging is a barrier towards achieving this goal, which runs counter to prevailing evidence-based guidelines and contributes to rising healthcare costs. Our objective was to evaluate the appropriateness of lumbar spine X-rays in a tertiary referral emergency department and assess whether physician specialization and years of experience influence appropriateness.

METHODS

Retrospective review of 1030 lumbar spine radiographs performed in an emergency department of an academic medical centre over a consecutive 3-month period. Referral indications were reviewed for adherence to 2021 American College of Radiology (ACR) appropriateness guidelines for low back pain, and referral pattern evaluated among physician groups based on specialist training and years in practice.

RESULTS

63.8% of lumbar spine radiograph were appropriate, with trauma being the most common indication. 36.2% orders were inappropriate, with low back pain of less than 6 weeks duration being the most common indication. Significant differences in inappropriate orders was found (p<0.001) across physician groups: qualified Emergency Medicine specialists (20.9% inappropriate orders), specialists in-training (27.8%) and non-specialists with ≥3 (60.0%) and <3 (36.9%) years in practice, respectively.

CONCLUSION

Approximately a third of lumbar spine radiography performed in the emergency room were inappropriately ordered by ACR guidelines; specialist training and years in practice affected referral patterns. Integrating evidence-based appropriateness guidelines into the physician order workflow and targeting older non-specialists may promote more judicious imaging and reduce healthcare costs.

Antibiotic therapy in the emergency room: Optimal prescription is indeed the best

INTRODUCTION

Emergency departments (ED) are pivotal for antibiotic prescription, of which the appropriateness and consequences have rarely been assessed.

METHODS

A retrospective study included patients referred to the ED and hospitalized with an advocated diagnosis of infection. Day-0 (ED initial prescription) and day-2 (reevaluation) antibiotic therapies were graded as optimal (if fully following the guidelines in terms of molecule, dose, and route of administration), adapted (if the prescribed molecule was microbiologically active but not recommended as first-line treatment, or in case of a wrong dose), or inadequate (other situations). The primary endpoint was onset of an unfavorable event (death, transfer to intensive care unit, or re-hospitalization). Prognosis factors associated with survival without unfavorable event were assessed by multivariate analysis.

RESULTS

We included 484 patients. Optimal, adapted, and inadequate initial prescriptions concerned 328 (67.8 %), 110 (22.7 %) and 46 (9.5 %) patients respectively. Compared with an optimal prescription, an initial adapted prescription was associated with a poorer prognosis (HR = 1.95, CI95% [1.18-3.22]; p = 0.01). Reevaluation was performed in 436 (90.1 %) patients. After reevaluation, optimal, adapted, and inadequate prescriptions concerned 326 (74.8 %), 64 (14.7 %), and 46 (10.5 %) patients respectively. After reevaluation, and as compared with optimal prescription, inadequate prescription was significantly associated with unfavorable events (HR = 3.52, CI95% [1.42-8.72]; p = 0.003).

CONCLUSION

Antibiotics are frequently prescribed in EDs. Antibiotic prescription has got to be optimal, and not simply adapted, so as to be associated with significant clinical benefit.

Anti-malarial drug use, appropriateness and associated factors among children under-five with febrile illnesses presenting to a tertiary health facility: a cross sectional study

BACKGROUND

Malaria is endemic in 95% of Uganda and constitutes the country's most significant public health problem-being the leading cause of morbidity and mortality, especially among children under five years of age. The current national malaria treatment policy is to use artemisinin-based combination therapy (ACT) as first-line treatment, and recommends parasitological confirmation of malaria before therapy. Adherence to this policy, however, remains suboptimal, with the self-initiated home-based therapy being common-posing undue exposures to, and pressure on the current artemisinin-based combinations, with the danger of emergence of drug resistance. The study evaluated the anti-malarial use and its appropriateness among febrile children under five presenting to a tertiary health facility in northern Uganda in light of the current malaria treatment policy.

METHODS

This was a cross-sectional study in a tertiary health facility in northern Uganda between March and September 2021. Children aged 6-59 months with fever were selected using systematic random sampling. A pretested interviewer-administered questionnaire was used to collect clinical data from the caregivers. Data were analysed using SPSS version 23. Descriptive statistics and multiple logistic regression models were applied. P-value < 0.05 was considered for statistical significance.

RESULTS

Seventy-two (34.3%) of the 210 children with fever in this study used anti-malarials prior to the hospital visit, 29.2% (21/72) of which were on a self-medication basis, 22.2% (16/72) were empiric prescriptions-all of which inappropriate, and only 48.6% (35/72) were prescribed based on a parasitological diagnosis of malaria. The most commonly used anti-malarials were artemether-lumefantrine 60/72 (88.3%), while a lesser proportion of quinine 7/72 (9.7%), artesunate 3/72 (4.2%) and dihydroartemisinin-piperaquine 2/72 (2.8%) were used. The factors independently associated with anti-malarial use among the children with febrile illnesses were duration of fever (p = 0.001); level of the nearest facility (p = 0.027), distance from the nearest health facility (p = 0.025), and caregivers' age (p = 0.038).

CONCLUSIONS

Inappropriate use of anti-malarials for childhood febrile illnesses is prevalent in the study setting, facilitated by the ease of over-the-counter access, empiric prescription and use of leftover anti-malarials. This calls for a need to address communities' health-seeking behaviour and the health providers' practice alike.

Does clinical decision support system promote expert consensus for appropriate imaging referrals? Chest-abdominal-pelvis CT as a case study

OBJECTIVES

We assessed the appropriateness of chest-abdominal-pelvis (CAP) CT scan use in the Emergency Department (ED), based on expert physicians and the ESR iGuide, a clinical decision support system (CDSS).

METHODS

A retrospective cross-study was conducted. We included 100 cases of CAP-CT scans ordered at the ED. Four experts rated the appropriateness of the cases on a 7-point scale, before and after using the decision support tool.

RESULTS

Before using the ESR iGuide the overall mean rating of the experts was 5.2 ± 1.066, and it increased slightly after using the system (5.85 ± 0.911 (p < 0.01)). Using a threshold of 5 (on a 7-level scale), the experts considered only 63% of the tests appropriate before using the ESR iGuide. The number increased to 89% after consultation with the system. The degree of overall agreement among the experts was 0.388 before ESR iGuide consultation and 0.572 after consultation. According to the ESR iGuide, for 85% of the cases, CAP CT was not a recommended option (score 0). Abdominal-Pelvis CT was "usually appropriate" for 65 out of the 85 (76%) cases (score 7-9). 9% of the cases did not require CT as first exam modality.

CONCLUSIONS

According to both the experts and the ESR iGuide, inappropriate testing was prevalent, in terms of both frequency of the scans and also inappropriately chosen body regions. These findings raise the need for unified workflows that might be achieved using a CDSS. Further studies are needed to investigate the CDSS contribution to the informed decision-making and increased uniformity among different expert physicians when ordering the appropriate test.

Appropriateness of MRI Requests for Low Back Pain and Neck Pain

BACKGROUND

There is a high prevalence of low back pain and neck pain in Canada, and a large proportion can be treated without spine magnetic resonance imaging (MRI). We hypothesized that there is overuse of lumbar and cervical spine MRI. The primary objective was to describe the proportion of appropriate, possibly appropriate, and inappropriate MRI requests for low back pain and neck pain.

METHODS

We conducted a retrospective observational study in the electromyography (EMG) clinic in Centre Hospitalier Universitaire de Sherbrooke. All ambulatory cases of low back pain or neck pain who had an EMG evaluation and a request of lumbar and/or cervical spine MRI between March 1, 2018, and May 31, 2018, were analyzed. One hundred and twenty MRI orders were classified as appropriate, possibly appropriate, and inappropriate according to the interactive decision support guide of Institut National d'Excellence en Santé et Services Sociaux for optimal use of MRI.

RESULTS

Sixty-three requests (53%) were classified as inappropriate, with a higher proportion in the cervical group (34 (64%)) than the lumbar group (28 (43%)). Appropriate and possibly appropriate requests were 19 (16%) and 38 (31%), respectively. The subgroup with an MRI ordered within 90 days of symptom onset had a similar proportion of inappropriate use.

INTERPRETATION

Our study demonstrates that despite recommendations against ordering spine MRI in low back pain or neck pain without red flags, there is an overuse of this imaging modality in our region, contributing to the delay in MRI access for appropriate indications.

SARS-CoV-2 caused a surge in antibiotic consumption causing a silent pandemic inside the pandemic. A retrospective analysis of Italian data in the first half of 2022

BACKGROUND

The phenomenon of antibiotic resistance shows no sign of stopping, despite global policies to combat it that have been in place for several years. The risk of forms of pathogenic microorganisms that are increasingly resistant to common antibiotics has led health authorities around the world to pay greater attention to the phenomenon. The worrying situation, has led to further recommendations from the World Health Organization (WHO) and national recommendations in Italy through the new National Plan against Antibiotic Resistance 2022-2025 (PNCAR 2022-2025).

AIM

This manuscript aims to raise the awareness of all health professionals to follow what is suggested by regulatory agencies and scientific societies.

METHOD

We conducted a retrospective study of antibiotic pharmacoutilization in Italy, in the Campania region at the Azienda Sanitaria Locale (ASL) Napoli 3 Sud, on consumption in the first half of 2022 in a population of more than 1 million people.

RESULT

The results indicate that consumption, based on defined daily doses (DDDs), is above the national average. Probably the COVID-19 pandemic has influenced this growth in prescriptions.

CONCLUSIONS

Our study suggests an informed and appropriate use of antibiotics, so as to embark on a virtuous path in the fight against antibiotic resistance.

Characteristics of dentists and patients associated with appropriate antibiotic prescriptions by French dentists: a cross-sectional study using Health Insurance databases

BACKGROUND

The use of antibiotics in dental care is often unnecessary or inappropriate. Our objectives were to identify (i) Clusters of dentists grouped according to their appropriateness score based on proxy indicators' results; and (ii) Dentists' and patients' characteristics associated with the appropriateness of antibiotic prescriptions.

METHODS

We used data of the Health Insurance reimbursement databases on antibiotics prescribed in 2019 by general dental practitioners of the Grand Est region in France. The appropriateness of antibiotic prescriptions was estimated by the results of recently published proxy indicators. We conducted a cluster analysis according to an appropriateness score calculated for each dentist, using the Ward method. We then conducted bivariate and multivariable analyses to identify characteristics associated with these clusters.

RESULTS

We included 3,014 dentists, who prescribed 373,975 antibiotics in 2019, and which were grouped into three clusters: average practices (n = 1,241), better (n = 686), and worse (n = 1,087) than average practices. Overall, dentists had more appropriate prescription practices when they were male (OR for belonging to cluster with "worse than average practices" = 1.37 (p = 0.003) for female), having a predominant surgery practice (p = 0.028) in the Lorraine area (p < 0.0001) for less years (p = 0.0002), when they had healthier patients (i.e., younger, with no chronic diseases, and who received less procedures), and when they had a more prudent use of drugs in general (i.e., less prescriptions of drugs, antibiotics, and non-steroidal anti-inflammatory).

CONCLUSIONS

We identified clusters and characteristics associated with the appropriateness of antibiotic prescriptions made by dentists, which might help guiding antimicrobial stewardship interventions.

Whole-body computed tomography as first-line imaging procedure to exclude cancer in patients with neurological suspicion of paraneoplastic syndromes: shall clinical practice adhere to recommendations?

INTRODUCTION

To assess the efficacy of whole-body computed tomography (WB-CT) as imaging procedure to exclude cancer in patients with neurological symptoms and signs at clinical onset.

METHODS

A retrospective observational study was designed to identify consecutive WB-CT requested by the Neurology Unit with a suspicion of an underlying tumor potentially linked to a paraneoplastic neurological syndrome (PNS) between January 2019 and February 2022. The following data were collected: diagnosis at admission and at discharge, the presence of onconeural antibodies, the scans dose length product (DLP), the estimated effective dose (ED), the total estimated time requested; the PNS-Care-Score was retrospectively calculated only in subjects with available antibodies.

RESULTS

The total number of patients included was 158. In 13/158 (positive group) a malignant or locally aggressive neoplasm was found while in 145/158 no malignant lesions were found on the WB-CT. Among the positive group, in 7/13 onconeural antibodies were diagnosed, resulting negative in all cases and the most frequent tumor was lung cancer (30.8%). PNS-Care-Score was of 6-7 in 2/7 (probable PNS) and in no case the PNS-Care-Score was ≥8 (definite PNS). The mean DLP for all the scans was 2798 ± 952 mGy cm (average estimated ED of 42 ± 14 mSv). The total estimated time requested for all scans was 11,060 min.

CONCLUSION

If a PNS is suspected, we encourage the prescription of unenhanced chest CT and/or abdomen/testis/female pelvis ultrasound and/or mammography based on clinical picture. The WB-CT using a single portal phase would be appropriate as a second-line technique while magnetic resonance imaging might be indicated for the exclusion of nervous system diseases.

IMPLICATIONS FOR PRACTICE

Our suggestion results in saving in terms of radiation exposure, financial resources and time.

Management of type 2 diabetes with a treat-to-benefit approach improved long-term cardiovascular outcomes under routine care

BACKGROUND

Results of cardiovascular outcome trials enabled a shift from "treat-to-target" to "treat-to-benefit" paradigm in the management of type 2 diabetes (T2D). However, studies validating such approach are limited. Here, we examined whether treatment according to international recommendations for the pharmacological management of T2D had an impact on long-term outcomes.

METHODS

This was an observational study conducted on outpatient data collected in 2008-2018 (i.e. prior to the "treat-to-benefit" shift). We defined 6 domains of treatment based on the ADA/EASD consensus covering all disease stages: first- and second-line treatment, intensification, use of insulin, cardioprotective, and weight-affecting drugs. At each visit, patients were included in Group 1 if at least one domain deviated from recommendation or in Group 2 if aligned with recommendations. We used Cox proportional hazard models with time-dependent co-variates or Cox marginal structural models (with inverse-probability of treatment weighing evaluated at each visit) to adjust for confounding factors and evaluate three outcomes: major adverse cardiovascular events (MACE), hospitalization for heart failure or cardiovascular mortality (HF-CVM), and all-cause mortality.

RESULTS

We included 5419 patients, on average 66-year old, 41% women, with a baseline diabetes duration of 7.6 years. Only 11.7% had pre-existing cardiovascular disease. During a median follow-up of 7.3 years, patients were seen 12 times at the clinic, and we recorded 1325 MACE, 1593 HF-CVM, and 917 deaths. By the end of the study, each patient spent on average 63.6% of time in Group 1. In the fully adjusted model, being always in Group 2 was associated with a 45% lower risk of MACE (HR 0.55; 95% C.I. 0.46-0.66; p < 0.0001) as compared to being in Group 1. The corresponding HF-CVM and mortality risk were similar (HR 0.56; 95%CI 0.47-0.66, p < 0.0001 and HR 0.56; 95% C.I. 0.45-0.70; p < 0.0001. respectively). Sensitivity analyses confirmed these results. No single domain individually explained the better outcome of Group 2, which remained significant in all subgroups.

CONCLUSION

Managing patients with T2D according to a "treat-to-benefit" approach based international standards was associated with a lower risk of MACE, heart failure, and mortality. These data provide ex-post validation of the ADA/EASD treatment algorithm.

Appropriateness of antibiotic treatment of acute respiratory tract infections in Tunisian primary care and emergency departments: a multicenter cross-sectional study

BACKGROUND

Little is known about the pattern and appropriateness of antibiotic prescriptions in patients with acute respiratory tract infections (ARTIs).

OBJECTIVE

Describe the antibiotics used to treat ARTIs in Tunisian primary care offices and emergency departments (EDs), and assess the appropriateness of their use.

METHODS

It was a prospective multicenter cross-sectional observational clinical study conducted at 63 primary care offices and 6 EDS during a period of 8 months. Appropriateness of antibiotic prescription was evaluated by trained physicians using the medication appropriateness index (MAI). The MAI ratings generated a weighted score of 0 to 18 with higher scores indicating low appropriateness. The study was conducted in accordance with the Declaration of Helsinki and national and institutional standards. The study was approved by the Ethics committee of Monastir Medical Faculty.

RESULTS

From the 12,880 patients screened we included 9886 patients. The mean age was 47.4, and 55.4% were men. The most frequent diagnosis of ARTI was were acute bronchitis (45.3%), COPD exacerbation (16.3%), tonsillitis (14.6%), rhinopharyngitis (12.2%) and sinusitis (11.5%). The most prescribed classes of antibiotics were penicillins (58.3%), fluoroquinolones (17.6%), and macrolides (16.9%). Antibiotic therapy was inappropriate in 75.5% of patients of whom 65.2% had bronchitis. 65% of patients had one or more antibiotic prescribing inappropriateness criteria as assessed by the MAI. The most frequently rated criteria were with expensiveness (75.8%) and indication (40%). Amoxicillin-clavulanic acid and levofloxacin were the most inappropriately prescribed antibiotics. History of cardiac ischemia ([OR] 3.66; 95% [CI] 2.17-10.26; p < 0.001), asthma ([OR] 3.29, 95% [CI] 1.77-6.13; p < 0.001), diabetes ([OR] 2.09, 95% [CI] 1.54-2.97; p = 0.003), history of COPD ([OR] 1.75, 95% [CI] 1.43-2.15; p < 0.001) and age > 65 years (Odds Ratio [OR] 1.35, 95% confidence interval [CI] 1.16-1.58; p < 0.001) were associated with a higher likelihood of inappropriate prescribing.

CONCLUSION

Our findings indicate a high inappropriate use of antibiotics in ARTIs treated in in primary care and EDs. This was mostly related to antibiotic prescription in acute bronchitis and overuse of expensive broad spectrum antibiotics. Future interventions to improve antibiotic prescribing in primary care and EDs is needed.

TRIAL REGISTRATION

the trial is registered at Clinicaltrials.gov registry (NCT04482231).

Antibiotic prescribing patterns at children's outpatient departments of primary care institutions in Southwest China

BACKGROUND

Inappropriate use of antibiotics in children is common in many countries. The purpose of the study was to explore patterns of antibiotic prescribing in children's outpatient clinics in primary care institutions in a province of southwest China.

METHODS

We obtained electronic prescription data from 75 primary care institutions in Guizhou province in 2020. The classification of incorrect spectrum of antibiotics, unnecessary use and combined use of antibiotics was based on the Guiding Principle of Clinical Use of Antibiotics (2015, China) and guidelines from the USA Centers for Disease Control and Prevention. Potential risk factors for inappropriate use of antibiotics were identified using bivariate analyses. The generalized estimation equation was used to identify independent predictors of inappropriate use of antibiotics.

RESULTS

A total of 158,267 antibiotic prescriptions were retrieved. Acute upper respiratory tract infections were the most common diseases, accounting for 74.9% of all prescriptions. The main antibiotic group used was penicillins (63.7%), followed by cephalosporins (18.8%). Of 137,284 visits, 18.3% of antibiotic prescriptions were appropriate and the percentage of unnecessary use, incorrect spectrum of antibiotics and combined use of antibiotics was 76.9, 2.4 and 2.4%, respectively. Physicians with lower professional titles and more than 40 years of work duration were relatively more likely to prescribe inappropriate antibiotics.

CONCLUSION

The inappropriate use of antibiotics in children is still prominent in primary care institutions of southwest China. The education and training of physicians and caregivers in these institutions should be strengthened.

Do we need blood culture stewardship programs? A quality control study and survey to assess the appropriateness of blood culture collection and the knowledge and attitudes among physicians in Swiss hospitals

BACKGROUND

Guidance for blood culture (BC) collection is limited. Inappropriate BC collection may be associated with potentially harmful consequences for the patient such as unnecessary laboratory testing, treatment and additional costs. The aim of the study was to assess the appropriateness of BC collection and related knowledge and attitude of precribers.

MATERIALS

We conducted a single-center quality control study to assess the appropriateness of BC collection according to the local guidelines in a Swiss university hospital in 2020 by combining three different approaches: point prevalence, patient-individual longitudinal and diseases-related analysis. Second, we conducted a survey regarding BC collection practices and knowledge among physicians in two non-university and one university hospital using an 18-item electronic questionnaire.

RESULTS

We analyzed 1114 BC collected in 344 patients. Approximately 40% of the BCs were collected inappropriately, in particular in diseases with low pretest probability of bacteremia such as non-severe community acquired pneumonia (CAP). Follow-up blood culture (FUBC) collection was inappropriate in 60%. Growth of a relevant pathogen was more frequently observed in appropriately than in inappropriately collected BCs (18% vs. 3%, p < 0.001). In the survey, uncertainty concerning the need of index BC collection was high in non-severe CAP and uncomplicated cellulitis.

CONCLUSIONS

Almost half of the BCs was not collected according to the guidelines, especially in non-severe CAP and in case of FUBCs. Substantial uncertainty among physicians regarding BC ordering practices was identified. The implementation of diagnostic stewardship programs may improve BC collection practices, increase adherence to local guidelines, and may help reducing unnecessary diagnostics and treatment.

Consensus among clinicians on referrals' priority and use of digital decision-making support systems

The growing demand for referrals is a main policy concern in health systems. One approach involves the development of demand management tools in the form of clinical prioritization to regulate patient referrals from primary care to specialist care. For clinical prioritization to be effective, it is critical that general practitioners (GPs) assess patient priority in the same way as specialists. The progressive development of IT tools in clinical practice, in the form of electronic referrals support systems (e-RSS), can facilitate clinical prioritization. In this study, we tested if higher use of e-RSS or higher use of high-priority categories was associated with the degree of agreement and therefore consensus on clinical priority between GPs and specialists. We found that higher use by GPs of the e-RSS tool was positively associated with greater degree of priority agreement with specialists, while higher use of the high-priority categories was associated with lower degree of priority agreement with specialists. Furthermore, female GPs, GPs in association with others, and GPs using a specific electronic medical record showed higher agreement with specialists. Our study therefore supports the use of electronic referrals systems to improve clinical prioritization and manage the demand of specialist visits and diagnostic tests. It also shows that there is scope for reducing excessive use by GPs of high-priority categories.

Antimicrobial therapy, resistance, and appropriateness in healthcare-associated and community-associated infections; a point prevalence survey

BACKGROUND

Data examining differences in antimicrobial therapy and its appropriateness between healthcare-associated infections (HAIs) and community-associated infections (CAIs) are limited. The objective was to compare antimicrobial therapy, resistance, and appropriateness between CAIs and HAIs.

METHODS

One-day point prevalence survey targeting admitted patients with active infections was conducted in six tertiary care hospitals. Antimicrobial appropriateness was decided based on hospital antimicrobial guidelines, clinical assessment, culture results, and other relevant investigations.

RESULTS

Out of 1666 patient records reviewed, 240 (14.4%) infection events were identified. Prevalence of infections treated with antimicrobials were 6.5% for HAIs and 7.1% for CAIs. The most commonly prescribed antimicrobials were carbapenems (19.6%), cephalosporins (14.8%), and vancomycin (13.2%), with some differences between HAIs and CAIs. The overall contribution of MDR pathogens to both HAIs and CAIs was similar (34.0% versus 34.3%, p = 0.969). ESBL was significantly associated with CAIs while other gram-negative MDR pathogens significantly associated with HAIs. Overall appropriateness of antimicrobial therapy was similar in HAI and CAI events (64.2% versus 64.7%, p = 0.934). However, it was highest in aminoglycosides (78.6%) and lowest in vancomycin (40.8%). It was lowest in bloodstream infections than other infections (48.5% versus 61% to 78%, p = 0.044).

CONCLUSION

Although the overall burden of MDR pathogens and appropriateness of antimicrobial therapy were similar in HAI and CAI events, there were some differences related to the type of MDR, type of antimicrobials, and type of infection. The current finding can guide training and educational activities of local antimicrobial stewardship initiatives aiming to improve antimicrobial therapy in hospital setting.

Design of experiments meets immersive environment: Optimising eating atmosphere using artificial neural network

Design of experiments (DOE) is a family of statistical tools commonly used in food science to optimise recipes and facilitate new food development. In a novel cross-disciplinary twist, we propose to adapt DOE approach to the optimisation of restaurant atmosphere. In this study, an artificial neural network (ANN) with particle swarm optimisation algorithm (PSO; hereafter ANN-PSO) was selected and compared with classical Response Surface Method (RSM) as ANN-PSO has been reported to yield better reliability and predictability compared to RSM. Recent research has increasingly demonstrated that perceived food quality, enjoyment, and willingness to pay are influenced by contextual factors such as lighting, decoration, and background noise/music. Moreover, virtual reality (VR) technology, which has become increasingly accessible, sophisticated, and widespread over the past years, presents a new way to study scenarios which may be otherwise too expensive/implausible to test in real life this includes delivering immersive environment. We hereby demonstrate a novel proof-of-concept study by varying the degree of illumination and of background sound level in an immersive restaurant setup. Participants (N = 283) watched immersive 360° videos while rating situational appropriateness and food wanting for two different dishes in various ambient conditions as determined by DOE's Central Composite Design (CCD). Participants did not actually consume the foods but rather only viewed them. Optimal restaurant lighting and sound levels were then estimated using ANN-PSO model which was found to be at 289 lux and -21.38 Loudness Unit Full Scale (LUFS) for burger and 186.9 lux and -30 LUFS for pizza. While the results of our study are of obvious interest to those in the hospitality industry, this work further highlights the transferability of methods across different disciplines and the applicability of time-tested methods to new emerging areas.

Development and evaluation of the accuracy of an indicator of the appropriateness of interventional cardiology generated from a French registry

Background

Development of appropriateness indicators of medical interventions has become a major quality-of-care issue, especially in the domain of interventional cardiology (IC). The objective of this study was to develop and evaluate the accuracy of an indicator of the appropriateness of interventional cardiology acts (invasive coronary angiographies (ICA) and percutaneous coronary interventions (PCI)) in patients with coronary stable disease and silent ischemia, automated from a French registry.

Methods

All ICA and PCI recorded in a Regional IC Registry (ACIRA) and operated for a stable coronary artery disease or silent ischemia from January 1st to December 31th 2013 in eight IC hospitals of Aquitaine, southwestern France, were included.

The indicator was developed to reflect European guidelines. Classification of appropriateness by the indicator, measured on the registry database, was compared to the classification of a reference standard (expert judgment applied through complete record review) on a random sample of 300 interventions.

Accuracy parameters were estimated. A second version of the indicator was defined, based on the analysis of false negative and positive results, and its accuracy estimated.

Results

The second indicator accuracy was: sensitivity 63.5% (95% confidence interval CI [51.7–75.3]), specificity 76.0% (95%CI [70.4–81.6]), PPV 43.0% (95% CI [33.0–53.0]) and NPV 88.0% (95% CI [83.4–92.6]). When stratified on the type of act, parameters were better for ICA alone than for PCI.

Conclusions

Accuracy of the indicator should raise with improvement of database quality. Despite its average accuracy, it is already used as a benchmark indicator for cardiologists. It is sent annually to each IC center with value of the indicator at the region level to allow a comparison.

Appropriateness of hospital admissions in a university hospital in Egypt: Analyzing a preintervention phase

BACKGROUND

Identifying the magnitude of this improper use and applying interventions to eliminate unnecessary hospitalization will reduce health-care expenditure, improve the quality of care for patients, and increase the accessibility to care for actual patients in need on waiting lists. Aim of Work To measures the rate of inappropriate admissions at the Ain Shams University Hospital.

METHODS

This research is the preintervention phase of a study conducted to improve the appropriateness of patient admission at this hospital. The appropriateness evaluation protocol (AEP) was used to review the appropriateness of 576 hospital admissions over 100 days. The patients' medical records were stratified according to the admission route into two groups, namely emergency and outpatient admission. Next, the systematic random samples were taken from each stratum based on the admission list of the previous day.

RESULTS

The results showed that 20.5% of the sampled cases were inappropriately admitted. Furthermore, a statistically significant difference was observed between appropriately and inappropriately admitted cases regarding gender and shifts during which admission occurred in addition to body systems affected; inappropriate admissions were more among females, and admissions occurred most frequently during the morning shifts (8:00 am-2:00 pm). The remaining other factors that were studied also proved insignificant.

CONCLUSION

It can be concluded that a considerable proportion of hospital admissions is inappropriate, especially in the elective surgery department, and these admissions vary according to patient's gender, shifts during which admission occurred, and the affected body systems.

RECOMMENDATIONS

Adopting hospital admission policies based on the AEP criteria in addition to training of physicians on these criteria would help prevent inappropriate admission and ensure optimization during use of hospital facilities.

Clinical utility of a pediatric hand exoskeleton: identifying users, practicability, and acceptance, and recommendations for design improvement

BACKGROUND

Children and adolescents with upper limb impairments can experience limited bimanual performance reducing daily-life independence. We have developed a fully wearable pediatric hand exoskeleton (PEXO) to train or compensate for impaired hand function. In this study, we investigated its appropriateness, practicability, and acceptability.

METHODS

Children and adolescents aged 6-18 years with functional limitations in at least one hand due to a neurological cause were selected for this cross-sectional evaluation. We characterized participants by various clinical tests and quantified bimanual performance with the Assisting Hand Assessment (AHA). We identified children whose AHA scaled score increased by ≥ 7 points when using the hand exoskeleton and determined clinical predictors to investigate appropriateness. The time needed to don each component and the number of technical issues were recorded to evaluate practicability. For acceptability, the experiences of the patients and the therapist with PEXO were evaluated. We further noted any adverse events.

RESULTS

Eleven children (median age 11.4 years) agreed to participate, but data was available for nine participants. The median AHA scaled score was higher with PEXO (68; IQR: 59.5-83) than without (55; IQR: 37.5-80.5; p = 0.035). The Box and Block test, the Selective Control of the Upper Extremity Scale, and finger extensor muscle strength could differentiate well between those participants who improved in AHA scaled scores by ≥ 7 points and those who did not (sensitivity and specificity varied between 0.75 and 1.00). The median times needed to don the back module, the glove, and the hand module were 62, 150, and 160 s, respectively, but all participants needed assistance. The most critical failures were the robustness of the transmission system, the electronics, and the attachment system. Acceptance was generally high, particularly in participants who improved bimanual performance with PEXO. Five participants experienced some pressure points. No adverse events occurred.

CONCLUSIONS

PEXO is a safe exoskeleton that can improve bimanual hand performance in young patients with minimal hand function. PEXO receives high acceptance. We formulated recommendations to improve technical issues and the donning before such exoskeletons can be used under daily-life conditions for therapy or as an assistive device. Trial registration Not appropriate.

Clinical outcomes of newly diagnosed, stable angina patients managed according to current guidelines. The ARCA (Arca Registry for Chronic Angina) Registry: A prospective, observational, nationwide study

BACKGROUND

Clinical outcomes of stable angina patients treated according to guidelines recommendations (medical therapy first, selective revascularization in high risk or unresponsive patients) are not fully known.

METHODS AND RESULTS

Eight hundred thirty-three patients with newly diagnosed, stable angina were enrolled in a prospective, observational, nationwide registry and followed for 1 year. Symptoms and quality of life were evaluated with the CCS angina grading, with a self-assessment scale and with the SAQ-7. A composite end-point of MACEs (all-cause death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for unstable angina) at 1 year was considered. Upon enrollment, all patients were prescribed guidelines directed medical therapy. After one month of therapy, angina relieved or improved in 47% of the overall population. Patients in CCS class I significantly increased from 28.4% at enrollment to 67.1% at 12 months, and the SAQ-7 score from 58.4 ± 20 to 85.9 ± 14. The rate of MACEs was low (2.9%) in the overall population. After one month of medical therapy, 40.6% of patients were referred for coronary angiography and revascularization for resistant symptoms (invasive strategy). Among these, 38.2% had normal coronary arteries and 47% actually underwent revascularization. No difference between invasive and medical groups was found at 12 months in symptoms, quality of life and MACEs, except for a greater improvement in self-assessed symptoms in the invasive group. Combined medical and invasive strategies left 28.5% of patients still symptomatic at the end of the study.

CONCLUSIONS

The study confirms the efficacy and safety of a tailored approach to stable angina, as recommended by guidelines, with medical therapy first followed by selective revascularization when needed.

The appropriateness of and barriers to glaucoma care delivery by Australian optometrists

CLINICAL RELEVANCE

Establishing the level of appropriateness and barriers to glaucoma care delivery by Australian optometrists are important first steps in developing tailored interventions aimed at improving glaucoma care delivery.

BACKGROUND

To determine the appropriateness of and barriers to glaucoma care by optometrists.

METHODS

A mixed method study was conducted. Phase I was a retrospective cross-sectional medical record audit that assessed glaucoma care appropriateness against 37 clinical indicators from a nationally representative sample of 42 optometry practices. In Phase II, focus groups and interviews involving 31 optometrists explored audit findings to identify barriers to appropriate glaucoma care. Barriers were analysed by deductive and inductive qualitative analysis. Saliency analysis was used to identify key domains that influence glaucoma care.

RESULTS

Appropriate glaucoma care was delivered for 63% (95% CI 61%, 64%) of the 420 patient encounters audited. Appropriate care was delivered above 80% for most (57%) indicators, while 14 (38%) indicators were delivered below 60% appropriateness. Good compliance to appropriate care was noted for key indicators of intraocular pressure measurement (90%, 95% CI 87%, 93%) and optic nerve head/retinal nerve fibre layer imaging (78%, 95% CI 74%, 82%). Important barriers identified were beliefs about expected outcomes, lack of perceived relevancy, time constraints, poor organisational culture, knowledge gaps, focusing on some aspects of glaucoma care to the detriment of others, the complexity of glaucoma care, information recall, and social norms.

CONCLUSION

Glaucoma care was appropriate in most patient encounters, with opportunity to improve some aspects of history taking and physical examinations. Barriers to glaucoma care were diverse, existing at both the practitioner and organisational levels. These findings provide direction for the development of a tailored improvement intervention.

Appropriateness of Endoscopic Procedures: A Prospective, Multicenter Study

INTRODUCTION

Advances in endoscopy and open-access systems led to an increase in endoscopic procedures. However, overuse of endoscopy has been consistently reported. This study aims to assess the appropriateness of esophagogastroduodenoscopy (EGD) and colonoscopy referral in the private and public setting.

PATIENTS AND METHODS

We conducted a prospective, multicenter study at 2 public and 5 private endoscopy units. Patients scheduled for elective EGD or colonoscopy were enrolled. Clinical data and endoscopy findings were recorded. Appropriateness of endoscopy was defined according to the American Society for Gastrointestinal Endoscopy guidelines (for EGD) and the European Panel on Appropriateness of Gastrointestinal Endoscopy II (for colonoscopy).

RESULTS

Regarding EGD: 215 patients enrolled (43.7% were males) with a mean age of 61.0 ± 15.1 years; 54.0% (n = 116) were in public hospitals. Referral by a gastroenterologist was made for 34.9% (n = 75). Appropriate indications were made for 62.3% (n = 134): 42.4% in private versus 79.3% in public endoscopy units (odds ratio [OR] 5.20; 95% confidence interval [CI] 2.85-9.49; p < 0.01). Rate of appropriate EGD was 74.7% for gastroenterologist referral and 56.1% for other specialties (OR 2.31; 95% CI 1.24-4.28; p < 0.01). Diagnostic yield for relevant findings was 47.9%. No association between indication appropriateness, gastroenterologist referral, and relevant endoscopic findings was found. Regarding colonoscopy: 287 patients enrolled (49.1% were males) with a mean age of 60.4 ± 14.4 years; 48.1% (n = 138) were in public hospitals. Referral by a gastroenterologist was made for 20.6% (n = 59). Appropriate indications were made for 70.0% (n = 201): 53.0% in private vs. 88.4% in public endoscopy units (OR 6.75; 95% CI 3.66-12.47; p < 0.01). Diagnostic yield was 57.1%. Relevant endoscopic diagnosis was associated with indication: 63.2% in the appropriate vs. 43.0% in the nonappropriate indication group (p < 0.05).

DISCUSSION

A significant percentage of endoscopies, mainly in the private setting, were performed without an appropriate indication. This influenced the diagnostic yield. The use of adequate criteria is fundamental for the rational use of an open-access system.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Evaluating implementation outcomes of a measure of social vulnerability in adults with intellectual disabilities

BACKGROUND

A test identified as valid and accurate in research will not automatically be considered appropriate by those involved in its use, or even be used in the first place. The Social Vulnerability Test-22 items [TV-22] is a measure specially designed for adults with intellectual disabilities (ID). This study aims to evaluate the implementation outcomes of the TV-22; more precisely its acceptability (e.g., complexity), appropriateness (e.g., perceived relevance) and the assessment fidelity (i.e., adherence to assessment guidelines) by special education practitioners.

PROCEDURES

Thirty-one practitioners (8 psychologists, 11 educators, 12 special education center managers) administered the TV-22 during an interview with an adult with ID. Semi-structured interviews were conducted to collect practitioners' opinions on the acceptability and the appropriateness of the TV-22 for their clinical practice. Quantitative analyses were performed to assess the fidelity of the assessments and the influence of some personal factors.

RESULTS

The results indicate a good appropriateness, a reasonable acceptability, - but a low assessment fidelity of the TV-22 by some practitioners. Psychologists stand out for a more rigorous use of the test.

IMPLICATIONS

Results highlight the importance of evaluating implementation outcomes when a new measure is developed to ensure its appropriateness and correct use by stakeholders.

Examination of the relationship between emergency department presentations and population mortality: a multicenter analysis of emergency department presentations during the COVID-19 pandemic

BACKGROUND

In the spring of 2020, Italy experienced a significant reduction in the number of emergency department (ED) presentations during the first wave of the COVID-19 pandemic. If ED access has an impact on patients' prognosis, such a reduction in ED presentations would be expected to correlate with a parallel increase in the mortality rate of the corresponding population. The aim of the present study was to evaluate the impact of reduced ED presentations on the all-cause mortality of the general population.

METHODS

Absolute and relative variation in ED accesses from March 1 to April 30 of both 2019 and 2020 in three hub hospitals in areas with different COVID-19 prevalence and age-standardized mortality data from January 1 to June 30 in 2019 and 2020 of the same areas were evaluated.

RESULTS

During March and April 2020, ED consults were decreased of approximately 50% in all three hospitals, as compared with the same months in 2019. There was a marked increase in cumulative mortality in Milan (high SARS-CoV2 infection spread zone) compared with the same period in 2019. In the other two municipalities (Ferrara and Perugia), which had intermediate and low levels of infection spread, the mortality in 2020 was not substantially changed from that of 2019.

CONCLUSIONS

Taking into account the increase in mortality due to SARS-CoV-2, reductions in ED access did not seem to affect death rates. If this finding will be confirmed, ED organization and access would need to be reconsidered.

Impact of implementing a Choosing Wisely educational intervention into clinical practice: The CW-SIMI study (a multicenter-controlled study)

OBJECTIVES

To evaluate the impact of an educational intervention based on the Italian Society of Internal Medicine Choosing Wisely (CW-SIMI) recommendations.

DESIGN

Multicenter, interventional, controlled study.

SETTING

Twenty-three acute-care hospital wards in Italy.

PARTICIPANTS

303 Physicians working in internal medicine wards.

INTERVENTION

An online educational course.

MAIN OUTCOMES

The rate of proton pump inhibitor (PPI) prescriptions, the number of days of central venous catheter (CVC) usage, and the duration of intravenous (IV) antibiotic prescriptions evaluated at one month (T1) and at six months (T2) after course completion. Patients admitted and discharged during a 30-day period before the educational intervention (T0, one year before T2) were considered the comparison group.

RESULTS

A total of 232 physicians completed the course, while 71 did not attend the course. Data from 608, 662, and 555 patients were analyzed at T0, T1, and T2, respectively. The rate of PPI prescriptions declined at one month (RR: 0.67, 95% CI: 0.52-0.87, p = 0.0005) and at six months (RR: 0.62, 95% CI: 0.46-0.84, p = 0.003), and the number of days of CVC usage was reduced at six months (9.13 days at T0 vs. 5.52 days at T2, p = 0.007). The duration of IV antibiotic prescriptions displayed a decreasing trend (7.94 days at T0 vs. 7.42 days at T2, p = 0.081).

CONCLUSIONS

A simple online educational intervention based on the CW-SIMI recommendations was associated with a clinically relevant reduction in the usage of PPIs and CVCs. Further studies are needed to confirm these findings and a possible benefit on patients' outcomes.

What can we learn from the SARS-COV-2 pandemic about the value of specific radiological examinations?

BACKGROUND

The SARS-COV-2 pandemic provides a natural intervention to assess practical priority setting and internal evaluation of specific health services, such as radiological services. Norway makes an excellent case as it had a very low infection rate and very few cases of COVID-19. Accordingly, the objective of this study is to use the changes in performed outpatient radiological examinations during the first stages of the SARS-COV-2 pandemic to assess the practical evaluation of specific radiological examinations in Norway.

METHODS

Data was collected retrospectively from the Norwegian Health Economics Administration (HELFO) in the years 2015-2020. Data included the number of performed outpatient imaging examinations at public hospitals and private imaging centers in Norway and was divided in to three periods based on the level of restrictions on elective health services. Results were analyzed with descriptive statistics.

RESULTS

In the first period there was a 45% reduction in outpatient radiology compared to the same time period in 2015-2019 while in period 2 and 3 there was a 25 and 6% reduction respectively. The study identified a list of specific potential low-value radiological examinations. While some of these are covered by the Choosing Wisely campaign, others are not.

CONCLUSION

By studying the priority setting practice during the initial phases of the pandemic this study identifies a set of potential low value radiological examinations during the initial phases of the SARS-COV-2 pandemic. These examinations are candidates for closer assessments for health services quality improvement.

The use of patient-reported outcome measures in hip and knee arthroplasty in Alberta

PROMs are part of routine measurement for hip and knee replacement in Alberta, Canada. We provide an overview of how PROMs are implemented in routine care, and how we use PROMs data for decision-making at different levels within the health system. The Alberta Bone and Joint Health Institute (ABJHI) ran a randomized controlled trial to determine the effectiveness and cost-effectiveness of an evidence-based care pathway for hip and knee arthroplasty in 2004. The study included several PROMs questionnaires: Western Ontario and McMaster Universities Osteoarthritis Index, Health Utility Index, Short Form 36 and the EQ-5D-3L. Subsequently, the focus shifted to spread and scale of the care pathway provincially. WOMAC and EQ-5D-3L and a patient experience survey were selected for provincial adoption – captured before surgery, three-months post-surgery, and 12-months post-surgery. These PROMs data were integrated into research and routine clinical practice at the micro, meso and macro levels. At the micro level, PROMs data are used at the individual patient and provider level for patients to provide input on their care and as a tool to communicate with their healthcare providers. We examined the relationship of appropriateness and patient reported outcomes in a prospective cohort study. We evaluated whether routinely collected PROMs could be integrated into a patient decision aid to better inform shared decision making. At the meso level, continuous quality improvement reports are provided routinely to individual health care providers, hospitals and clinics on their performance against the measurement framework and standard key performance indicators. At the macro level, PROMs data are used to evaluate system performance by comparing outcomes across different jurisdictions or over time and support health policy decision making. Combined with administrative databases, we have used simulation models to reflect transition through the continuum of care from disease onset through end-stage care regarding the burden of disease, healthcare resource requirements and associated healthcare costs. The addition of PROMs data in clinical repositories and analyses enables the system to identify and address issues of continuous quality improvement against a measurement framework of performance indicators and to explicitly recognize the trade-offs that are inherent in any resource-constrained system.

[Prescription appropriateness in elderly patients with polypharmacy in primary care: Cluster-randomized controlled trial PHARM-PC]

Objetivos

Evaluar la efectividad de la revisión sistemática de medicación realizada por farmacéutico sobre medicaciones potencialmente inapropiadas (MPI), resultados en salud y costes.

Diseño

Ensayo clínico prospectivo, abierto, controlado y aleatorizado por clústeres.

Emplazamiento

Seis centros de atención primaria de las Islas Baleares.

Participantes

Se incluyeron 42 clústeres (21 por grupo), y 549 pacientes de ≥ 65 años y ≥ 5 medicamentos crónicos, de los cuales 277 se asignaron al Grupo Intervención (GI) y 272 al Grupo Control (GC). Se excluyeron pacientes: institucionalizados, desplazados, atendidos habitualmente por la sanidad privada, o en atención domiciliaria.

Intervención

Detección de MPI por parte del farmacéutico mediante combinación de métodos explícitos e implícitos y comunicación de las alternativas terapéuticas más apropiadas al médico prescriptor.

Mediciones

Se evaluaron la proporción de pacientes con MPI y número medio de MPI/paciente (variables principales); así como morbilidad, mortalidad, y costes (variables secundarias).

Análisis estadístico

Siguiendo el principio de intención de tratar, se compararon las variables cuantitativas y cualitativas mediante las pruebas t Student y X², respectivamente. Los resultados se expresaron como diferencia de proporciones para variables cualitativas y diferencia de medias para cuantitativas, con los correspondientes intervalos de confianza 95% (IC 95%).

Resultados

Después de la intervención, la proporción de pacientes con MPI disminuyó un 13,7% (IC 95%: 9,3; 18,2) más en GI que GC. El número medio de MPI/paciente y coste medio de MPI/paciente disminuyeron en 0,43 (IC 95%: 0,32; 0,54) y 72,11€ (IC 95%: 26,15; 118,06) más en GI que GC, respectivamente. Sin embargo, no se observaron diferencias estadísticamente significativas en morbilidad, mortalidad ni en costes de episodios asistenciales.

Conclusiones

La detección de MPI y emisión de recomendaciones por el farmacéutico pudo contribuir a reducir significativamente MPI y gasto en medicamentos, pero sin alcanzar diferencias estadísticamente significativas en morbimortalidad ni costes de episodios asistenciales.

Factors associated with the appropriateness of antibiotics prescribed in French general practice: a cross-sectional study using reimbursement databases

OBJECTIVES

Identifying characteristics associated with the appropriateness of antibiotic prescriptions is useful to guide antibiotic stewardship interventions. Proxy indicators estimating the appropriateness of antibiotic prescriptions at the general practitioner (GP) level have recently been validated. Our objectives were to identify (a) clusters of GPs according to their appropriateness score based on these proxy indicator results, and (b) GPs', patients' and practices' characteristics associated with inappropriate prescriptions.

METHODS

We conducted a cross-sectional observational study analysing antibiotics prescribed by GPs in one large French region in 2019, using the Health Insurance databases. We identified clusters of GPs according to their appropriateness score calculated from ten proxy indicators' results. We then analysed the association between the clusters with more inappropriate practices compared with the one with less inappropriate practices, and GPs', patients', and practices' characteristics. We performed bivariate and multivariable analyses using logistic polytomous regressions.

RESULTS

We included 4819 GPs who were grouped into three clusters. GPs who belong to the clusters with more inappropriate practices were more likely to practice in certain geographical area, to be male, not to have a particular medical practice, to be practicing for longer, to have more patients and consultations, to have a higher proportion of elderly patients, and to prescribe more drugs, more antibiotics and a higher proportion of broad-spectrum antibiotics.

CONCLUSION

We identified clusters of practice as well as factors associated with the appropriateness of antibiotic prescriptions, using routinely collected data. This might help to guide antibiotic stewardship interventions.

Observing the use of knee arthroplasty appropriateness tools in clinical practice: do appropriateness criteria tools predict surgeon decision-making?

OBJECTIVE

The primary aim of this study was to evaluate the agreement between surgeons and two validated total knee arthroplasty (TKA) appropriateness tools, and secondarily to compare Australian appropriateness rates to those reported internationally.

METHODS

A consecutive sample of patients from one public hospital arthroplasty clinic and a convenience sample from private rooms of surgeons in New South Wales, Australia (n = 11), referred for surgical opinion regarding TKA were enrolled over 1 year. Surgeons applied appropriateness tools created by Escobar et al. and the American Academy of Orthopaedic Surgeons (AAOS). Correlation between the appropriateness tools and surgeon's decisions were evaluated.

RESULTS

There were 368 patients enrolled, and contrasting rates of being "appropriate" for surgery were identified between the Escobar (n = 109, 29.6%) and AAOS (n = 292, 79.3%) tools. Surgeon agreement with the Escobar tool was substantial (ĸ = 0.61, 95%CI: 0.53-0.69) compared to slight with the AAOS tool (ĸ = 0.11, 95%CI: 0.06-0.16). Of those advised against TKA (n = 179, 48.6%), the AAOS tool suggested many patients (n = 111, 62.0%) were "appropriate" compared to the Escobar tool (n = 12, 6.7%).

CONCLUSIONS

Surgeons rated patients seeking opinion for TKA as appropriate over half the time, however the AAOS tool had low correlation with surgeons as opposed to the Escobar tool. This was illustrated by both tools rating a majority of patients to be operated on as appropriate, but only the AAOS tool considering most patients not chosen for surgery to be appropriate. When comparing previously published appropriateness rates, appropriateness in Australia, USA, Spain and Qatar was found to be similar.