Patients without records and records without patients: review of patient records in primary care and implications for surveillance of antibiotic prescribing in rural China

Rachel Kwiatkowska,Xingrong Shen,Isabel Oliver,Helen Lambert,Jing Cheng,Manman Lu,Matthew Hickman,Debin Wang

doi:10.1186/s12913-020-05308-0

Abstract

BackgroundWe need to monitor patterns of antibiotic prescribing in order to develop and evaluate antibiotic stewardship interventions in rural China. As part of a multidisciplinary study of antibiotic use in Anhui Province we assessed the validity of electronic records (e-records) as a source of surveillance data.MethodsOne township healthcare centre and one village clinic were selected in each of three different counties. Patients with symptoms of Upper Respiratory Tract Infection (URTI), exacerbation of Chronic Obstructive Pulmonary Disease (COPD) or Urinary Tract Infection (UTI) were recruited consecutively. Researchers observed and documented clinic consultations and interviewed each of the study participants. E-records were compared to clinic observations and patient interviews.ResultsA total of 1030 patients were observed in clinic. Antibiotics were prescribed in 917 (89%) of consultations. E-records were created only for individuals with health insurance, with considerable between-site variation in completeness (0 to 98.7% of clinic consultations) and in the timing of documentation (within-consultation up to weeks afterwards). E-record accuracy was better in relation to antibiotics (82.8% of e-records accurately recorded what was prescribed in clinic) than for diagnosis and symptoms (45.0 and 1.1% accuracy). Only 31 participants (3.0%) presented with UTI symptoms.ConclusionsWe have confirmed very high rates of outpatient antibiotic prescribing in rural Anhui province. E-records could provide useful information to inform stewardship interventions, however they may be inaccurate and/or biased. Public Health authorities should focus on improving technical infrastructure and record-keeping culture in outpatient settings. Further research is needed into community treatment of UTIs.

Highlights

Antimicrobial resistance (AMR) is recognised as one of the greatest public health challenges of our time, predicted to cause an additional 10 million deaths per year by the year 2050 if current global trends prevail [1]
Surveillance of antibiotic use is of vital importance to provide clinicians with feedback to inform prescribing practices, and to educate the public to reduce inappropriate demand for antibiotics
E-records are available for the majority of outpatient consultations and potentially a valuable source of antibiotic surveillance data though issues with coverage and accuracy undermine the validity of these records for surveillance of infections

Summary

Introduction

Antimicrobial resistance (AMR) is recognised as one of the greatest public health challenges of our time, predicted to cause an additional 10 million deaths per year by the year 2050 if current global trends prevail [1]. The National Essential Medicines System (NEMS) scheme, introduced in 2009, allows community hospitals and healthcare centres obtain medications from a provincial supplier to sell to patients at cost price [3]. The NEMS implemented protocols and guidelines for the appropriate use of medicines, and the Chinese government launched a campaign in 2011 to reduce inappropriate use of antibiotics in hospitals [2, 6, 7]. These measures have had some effect, not uniformly across all provinces, nor to the levels recommended by the World Health Organization (WHO) [8]. As part of a multidisciplinary study of antibiotic use in Anhui Province we assessed the validity of electronic records (e-records) as a source of surveillance data

Objectives

Methods

Results

Discussion

Conclusion